Dermatalogy Questionnaire New Patient Questionairre Your Information Your First and Last Name * Email Best Phone Number * Your Pet's Information 1. Name * 2. Approximate Age * 3. How long have you had your pet? * 4. What other pets do you have living in your household? Dogs Cats OtherOther 5. Has your pet ever lived outside the geographic area? YesNo 5a. Where else has your pet lived? * 6. For cat owners, Is your cat: Indoor Only Indoor and Outdoor 7. Do any other pets in the household have skin problems? 8. Are there any people in the household that are itchy or have skin lesions? 9. At what age did the problem start? 10. Where on the body did this start? 11. Where on the body did it progress? 12. If your pet is itchy (do you see him/her lick, bite, chew or scratch)? YesNo 12a. Where on the body does this occur? Paws Ears Legs Underarms Face Rump Tail Belly OtherOther 13. Is your pet itchy year round? YesNo 13a. Was your pet always itchy year round? 13b. When is your pet itchy? Winter Spring Summer Fall 14. On a scale of 1-10 how itchy is your pet? (1 = not itchy, 10 = licking, biting, chewing, scratching all the time)? 12345678910 15. Please list your pets’ current diet including all treats, table food and raw hides: 16. Is your pet on flea prevention? Is so what Brand? 17. Does your pet take flavored heartworm prevention? 18. Please list all the medications 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? Add Remove Do you give permission for Golden Gate Veterinary Specialists to post photos of your pet on our website or social media? Yes No Submit
