Dermatology Questionnaire Dermatology - New Patient Questionnaire Your Information Your First and Last Name * Email * Best Phone Number * Your Pet's Information 1. Name * 2. Approximate Age * 3. How old was your pet at adoption? * 4. What other pets do you have living in your household? * Dogs Cats None OtherOther 5. Has your pet ever lived outside the geographic area? * YesNo 5a. Where else has your pet lived? * 6. How much time does your pet spend INDOORS (0-100%)? * e.g.: 25% outdoors, 75% indoors 7. Please tell us what problem(s) your pet is coming in to have addressed 8. At what age did the problem start? * 9. Where on the body did this start? * 10. Where on the body did it progress? * 11. Is your pet itchy? This may include licking, biting, chewing, scratching, or rubbing * YesNo 11a. Where on the body does this occur? * Paws Ears Legs Underarms Face Rump Tail Belly OtherOther 12. Is your pet itchy year round? * YesNo 12a. If yes, has it always been that way? * YesNo 12b. If your pet is NOT itchy year round, which season(s) are they itchy? * Winter Spring Summer Fall 13. Have you noticed any possible "triggers" for your pet's symptoms (i.e., time of day, certain weather or seasons, specific areas or environments, certain foods, etc.) If so, please list: * 14. On a scale of 1-10 how itchy was your pet over the last 2 weeks? (1 = not itchy, 10 = licking, biting, rubbing, chewing, scratching all the time)? * 12345678910 15. On a scale of 1-10 how itchy was your pet over the last year? (1 = not itchy, 10 = licking, biting, rubbing, chewing, scratching all the time)? * 12345678910 16. Any pets affected? * YesNoN/A 17. Any humans affected? * YesNo 18. Please list your pet’s regularly eaten food(s) and if they have previously had a prescription food trial * 19. Does your pet eat a raw or freeze-dried diet? 20. What times of year does your pet receive flea preventative? What brand? * 21. Which of your pets receive flea preventative? * All of my pets Some of my pets None of my pets 22. Does your pet take flavored heartworm prevention? * YesNo 23. Is your pet up to date on vaccines? * YesNo 22. Please list all the medications and ear/skin topicals your pet is currently receiving or has received in the past (if you have multiple medications, please fill the fields below for the first medication, then click the "add" button at the bottom to respond to all fields for the 2nd medication, and so on) Medication Dose/strength Dates received Did this help? plus1 Add minus1 Remove 23. Does your pet have any other previously diagnosed conditions (examples: diabetes, IBD, etc.) or symptoms (examples: changes to thirst, energy level, mobility, etc.) * 24. Do you give permission for Golden Gate Veterinary Specialists to post photos of your pet on our website or social media? * Yes No If you are human, leave this field blank. Submit