Dermatology Follow- Up questionnarire

IMPORTANT INFORMATION:

If you do not know the answer to a question or do not understand the question, leave it blank. Please do not guess.

Owner Name

Phone Number

Pet Name

Sex

What is the current skin / ear problem? (Odor/redness/itching/head shaking/Dandruff/Dry Skin/Oily/ Greasy skin/Darkening of Skin/Hair loss)

Which areas is your pet itching the most?

Is your pet on allergy vaccine (allergy specific immunotherapy)? (yes/no)

If yes, which of the following methods is being used for immunotherapy: (oral drops/Injectable theraphy) Please list the dosage and frequency of immunotherapy administration

Which medications have been used since your last dermatology visit? Please include all oral, topical, injectable and shampoo therapy administered:

Has any of your contact information (contact email, phone number, address, etc) or family veterinarian changed since your last visit with us? If yes, please provide the current information:

Dermatology Follow- Up questionnarire

Dermatology Follow- Up questionnarire

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