Dermatology History Questionaire - Bay Veterinary Group Ltd

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Dermatology History

Owners Full Name

Email Address

Date

Dog's name

Breed

Age

Does your dog show any signs of itch, such as:

Scratching

Licking

Biting/chewing

Rolling/rubbing

Head Shaking

Scooting

Other

How long has your dog been itching for?

Does the skin problem happen:

Continuously/year-round

Seasonally ( e.g. Spring)

Intermittently

Randomly/no discernible pattern

Don't know

My animal hasn't experienced a skin problem before

At what age did your dog first start showing signs of a skin problem?

What did you notice first- the itch or skin changes(if any)?

Is you dog currently receiving any flea or tick treatment?

If yes, please provide details of the product(s) given.

How often do you give it?

When was it last given?

Have any medications been given for the current skin problem and/or previous skin problems?

If yes, please provide details of the medication(s) given:

What was the response to treatment?

Full resolution

Partial resolution

No effect

Is your dog currently receiving any other medications? (e.g. heart medication etc)? If yes, please list them

Please describe what is most concerning you about your dog's skin problem, so we can address during the appointment.

Please correct the errors above and try again.

Bay Veterinary Group Ltd

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