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? * Please Choose OneYesNo 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 about the 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? * 11a. Is your pet itchy? This may include licking, biting, chewing, scratching, or rubbing * Please Choose OneYesNo 11b. Where on the body does this occur? * Paws Ears Legs Underarms Face Rump Tail Belly OtherOther 11c. Is your pet itchy year round? * Please Choose OneYesNo 11d. If your pet is NOT itchy year round, which season(s) are they itchy? * Winter Spring Summer Fall 12. 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, vaccines, medication, etc.) If so, please list: * 13. 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 14. 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 15. Any pets having similar lesions? * Please Choose OneYesNoN/A 16. Any humans having similar lesions? * Please Choose OneYesNo 17. Please list your pet's regularly eaten food(s) * 18. Has your pet ever eaten a veterinarian-prescribed 'hydrolyzed' or 'novel protein' diet? NoYes 18a. What is the name of the diet? 18b. How long was the diet eaten? 18c. Was there any improvement from this diet? 19. Does your pet eat a raw or freeze-dried diet? * Please Choose OneNoYes 20a. What times of year does your pet receive flea preventative? * 20b. What brand of flea prevention does your pet receive, if any? * 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? * Please Choose OneYesNo 23. Is your pet up to date on vaccines? * Please Choose OneYesNo 24. 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 Currently Receiving? Yes No Did this help? plus1 Add Another minus1 Remove 25. Does your pet have any other previously diagnosed conditions (examples: respiratory illness, diabetes, IBD, kidney disease, heart disease, etc.) or symptoms (examples: vomiting, diarrhea, changes to thirst, energy level, mobility, coughing, sneezing, etc.). If so, please list * 26. Do you give permission for Golden Gate Veterinary Specialists to post photos of your pet on our website or social media? * Yes No Submit If you are human, leave this field blank.
