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 Itching/Scratching Otitis (ear infections) Licking/Chewing Skin lesions (sores) Changes in skin (reddish brown stains, discoloration and/or areas that are thick and leathery) Other_____________________________________________ 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 SEVERTIY OF SCRATCHING/LICKING/CHEWING____________________________ 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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