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Microsoft word - pruritus history form.docSkin 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.
Please check any that describe your pet and circle problem areas on the drawing.
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
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
• 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
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?___________________
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?
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?
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
Totally inactive Much less active Somewhat less active No change
Unsocial A lot less social Somewhat less social No change
Fewer walks No longer sleeps in bed/same room Interacts less with family
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) __________________________________________
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:
Lesion appearance and locations can provide valuable clues.
• 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
Obstétrique, gynécologie et sage-femme Accompagner l'arrêt de la lactation sans bromocriptine : partage d'expérience / Marie-France Morinaux-HardebolleIN : Profession sage-femme, No 196 (juin 2013), pp. 26-28Algies pelvipérinéales / Chantal Fabre-ClergueIN : Profession sage-femme, No 196 (juin 2013), pp. 39-40Allaitement maternel : liberté individuelle sous influences / Irène Capponi