Dermatology Client Questionnaire Form


U of MN Veterinary Medical Center
Dermatology Service
Telephone: 612-624-4831
email: vetderm@umn.edu

Please assist us by completing the requested information
 

UMN Case # / PA Number

Appointment Date / Time (if known) Date:
Time:
   
Client's Name
Address
City, State, Zip
City:
State:
Zip:
Phone #     

Client's Email

   
Pet's Name   
Species 
Breed  
Gender  
Birthdate or Age   DOB: or Age:

 

 


Reason for Visit:

Expectations for Visit:

   

 

Part I: History

 
   
1. How long have you owned this pet?
   
2. From what source did you get this pet?
   
3. Do the parents or siblings have a skin / ear problem?
No Unkonwn
   
4. When did this problem begin?
   
5. Is this the first time your pet has had a skin/ear problem?
Yes No
  If No, when was the first occurance?
   
6. What do you think caused the problem?
   
7. Is this problem seasonal?
No Unkonwn
  If Yes, which seasons?

Summer Fall Winter
   
8. Is this problem year-round?
No Unkonwn
  If Yes, which season(s) is/are worse?

Summer Fall Winter
   
9. What area(s) of the body was involved first?
   
10. What area(s) of the body was involved second?
   
11. How did the involved skin change as time went on?
   
12. Other pets in the household?
No  
  If Yes, include species:
   
13. Are any other animals in the household affected?
No  
   
14. Exposure to other animals outside of household? If yes, please specify:
No  
Specify:
   
15. Are any humans in the household affected?
No  
   
16. Percentage of time spent indoors?
   
17. Describe your pet's housing environment?
   
18. What is your pet's bed made of?
   
19. Fleas / Lice / Ticks / other parasite problems in the home?
   
20. Does your pet swim?
No  
   
21. Does your pet hunt? If yes, what does it hunt
No  
If yes, what:


Part II: Medical History
 
   
1. Is your pet taking any medications currently?
No  
  If Yes, please list medications including dosage and frequency:


Response to current medication(s):
   
2. Please list any previous medications and responses
   
3. How often do you bathe your pet?
   
4. What kind of shampoo & conditioners are used?
   
5. What improves skin condition?
   
6. Current diets and treats - include amount & frequency:
   
7. Has your pet been on a food trial?
No Unknown
  If Yes, which food?


If Yes, duration of food trial?


How much improvement was seen?

Fair (0-25%) Good (26-50%) Very Good (>50%)


Was any chewable or flavored medication (including heartworm) given during the food trial?

No  
   
8. Has your pet been allergy tested?
No Unknown
  If Yes, was it a:

Blood Test Both Skin & Blood Test Unknown


If Yes, has your pet been on allergy shots?

No  


If Yes, for how long?


How much improvement was seen?

Fair (0-25%) Good (26-50%) Very Good (>50%)
   

9. List preventative medications used and frequency (heartworm, flea and tick control)

   
10. Is your pet up-to-date with vaccinations?
No  


List vaccine and dates given

   
11. Any adverse drug or vaccination reaction?
No  


If Yes, please describe

   
12. Any previous illness, surgery or traum?
No  


If Yes, please describe

   


Part III: Dermatological Symptoms
 
   
1. Does the skin problem itch?
No  
   
2. Does your pet lick?
No  

If Yes, location and frequency:

   
3. Does your pet chew at himself/herself?
No  

If Yes, location and frequency:

   
4. Does your pet rub?
No  

If Yes, location and frequency:

   
5. Does your pet scratch/itch?
No  

If Yes, location and frequency:

   
6. If there is scratching/itching, what came first:
   
7. Does your pet scoot his/her rear end?
No  

 

   
8. Is there discharge coming from the ears?
No  
   
9. Is there odor coming from the ears?
No  
   
10. Does your pet shake its head frequently?
No  
   


Part IV: General Symptoms
 
   
1. Any eye or nasal discharge?
No  

If Yes, please describe

   
2. Any coughing or sneezing?
No  

If Yes, please describe

   
3. Any vomiting or diarrhea?
No  

If Yes, please describe

   
4. Any change in urination or defecation?
No  

If Yes, please describe

   
5. Number of bowel movements per day?
   
6. Any change in food or water intake?
No  

If Yes, please describe

   
7. Any changes in weight?
No  

If Yes, please describe

   
8. Any changes in activity or mobility?
No  

If Yes, please describe

   
9. Any abnormal behavior concerns?
No  

If Yes, please describe

   
10. At veterinary visits, does your pet exhibit any of these signs?
   
10. Any hearing changes or concerns?
No  

If Yes, please describe

   
12. Any other health concerns?
No  

If Yes, please describe

   


Part V: Other Questions or Concerns
 
   
Are you or anyone in your immediate family a health care provider? If yes, please specify.

No  

If Yes, please specify the type of care provider

 
Does your pet have pet insurance?

No  
 
Please list any other questions or concerns