Microsoft word - pruritus history form.doc

Skin Problems Questionnaire
Date___________ Name of pet________________ Owner’s name_______________________
A thorough history can help us find the source of you pet’s itching more quickly.
Please answer the following questions to help guide the diagnostic process.
Physical Evaluation
Please check any that describe your pet and circle problem areas on the drawing.
 Hair loss
 Foul odor
 Inflammation or redness
 Otitis (ear infections)
 Skin lesions (sores)
 Changes in skin (reddish brown stains, discoloration and/or
areas that are thick and leathery)
Circle Problems Areas
Has your pet ever had ear problems?  Yes  No
Does your pet have any chronic gastrointestinal signs like diarrhea or vomiting?  Yes  No
Severity Evaluation
On a scale of 0 to10, rank the severity of your pet’s symptoms.
SEVERITY OF CONDITION OVERALL__________________________________________
0 1 2 3 4 5 6 7 8 9 10
No symptoms Severe
SEVERTIY OF SKIN LESIONS__________________________________________________
0 1 2 3 4 5 6 7 8 9 10
No lesions Severe
0 1 2 3 4 5 6 7 8 9 10
No signs Severe
Onset and Seasonality Evaluation
Is this the first time your pet has experienced these symptoms?  Yes  No
If no:
• At what age did the symptoms first occur?  <1yr  1-3yrs  4-7yrs  7+ yrs • Has it occurred around the same time of year each year? • Approximate time of year symptoms occur ______________________________ How long have the current symptoms been going on? ______________________
Did the itch start gradually and over time slowly become worse?
Did the itching come on all of a sudden? Were there visible skin lesions first or itching first?  Lesions first  Itch first  Simultaneous
Parasite Control
Is your pet on flea/heartworm preventative?
• what products(s)__________________________________________ • What months do you administer the preventative?_____________________________ • When was the last time you administered the parasite control?___________________
Lifestyle Evaluation
Where does your pet live?  Indoors  Outdoors  Both
• If outdoors, please describe environment _____________________________________ • If yes, do these pets have the same symptoms?  Yes  No If these pets are cats, do they go outside? In the last year has your pet been to any of the following: boarding facility; obedience school; training; groomer’s; dog park; doggie daycare; pet store? • If yes, when was the last time? _____________________________________________ Have you taken your pet on a trip to another location? • If yes, please indicate when and location ______________________________________ Have you taken your dog camping, in the woods, or on a walking trail?  Yes  No Have you used any new shampoo or topical skin treatments recently? Are any humans in your household exhibiting signs?
Dietary Evaluation
What pet food are you feeding? _________________________________________
Do you feed the same food all the time or provide a variety?  Always same  Variety
Have you changed his or her diet recently?

Relationship/Behavioral Evaluation
Indicate if and how your pet’s itching has affected his/her behavior and relationship with you. (Circle
all appropriate answers)
Sleeps Through the Night
Always Usually Occasionally Never
Activity Level
Totally inactive Much less active Somewhat less active No change
Social Behavior
Unsocial A lot less social Somewhat less social No change
Relationship Changes
Fewer walks No longer sleeps in bed/same room Interacts less with family
Prior Treatments
Has your dog been treated for itching before?  Yes  No
Indicate previous treatments administered to your dog: (check all that apply)
 Steroids (prednisone, etc)  Shampoos  Sprays  Ointments
 Antibiotics (cephalexin, Simplicef™, Convenia™)
 Hypoallergenic food . Please name brands/types used ___________________________
 Fatty acids  Antihistamines (Benadryl™, hydroxyzine, etc)
 Immunotherapy (Atopica™, cyclosporine, etc)
 Other (please specify) __________________________________________
Next Steps
Based on the information you have provided, some or all of the following may be performed to further
diagnose the problem and come up with a treatment plan:
Physical Exam:
Lesion appearance and locations can provide valuable clues.
Laboratory Testing:
• Ear Swab - To identify any infections in the ear including yeast and/or bacteria.
• Skin Scrape - To detect scabies or demodex mites.
• Hair Pluck- To look for mite eggs and yeast spores.
• Cytology - To evaluate presence and appearance of skin cells, and check for presence of yeast
• Blood and urine tests – underlying systemic conditions can predispose pets to skin problems. Thank you for taking the time to fill out this form. It will be a valuable tool in helping your pet feel better. You may bring it with you to your appointment, or fax it to the office in advance. Please feel free to contact us with any questions. Four Paws Animal Hospital & Wellness Center


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