Owner's name
*
Patient's name
*
Patient gender
*
Male
Female
Patient breed
*
Primary complaint
*
If itching, where?
Face
Feet
Armpits
Tail
Back
Everywhere
If itching, when?
Constantly
Sporadically
Do any of the following occur?
Sores
Scabs
Dandruff
Hair loss
Odour
Hives
Ear problems
Weight loss
Weight gain
Ravenous appetite
Vomiting
Diarrhoea
Increased thirst
Any other signs?
Sneezing
Coughing
Wheezing
Snorting
Weepy eyes
Sweating
When was this first noticed and what time of the year?
Are the symptoms getting worse?
What aggravates the symptoms?
What helps the symptoms?
Any other illnesses?
What are you feeding your pet?
Canned food
Dry food
Fresh meat
Table scraps
Vitamins
Other
Did you feed a special diet? if so, please specify
Allergic to drugs, food or medications? if so, please specify
Do you have any other pets?
Cats
Dogs
Birds
Other
Do any of these have skin problems? if so, please specify
Do any of the humans in the household have skin problems?
Do any relatives of your pet with skin problems? if so, please specify
Where does this pet sleep?
What do you do for flea control?
Are the other pets treated as well? If so how?
When did you see a flea on your pet last?
How often do you prefer to bath your pet?
Weekly
Fortnightly
Monthly
Infrequently
Does bathing...
help?
aggravate?
neither?
Previous medications
Shampoos
Rinses
Powders
Sprays
Creams/ointments
Tablets
Injections
Ear drops
Eye drops
Currently on heartworm preventative
What date was the last tablet given and what was the response?
What date was the last injection given and what was the response?
What do you think is the cause of this problem?
Has your pet been receiving Trocoxil (monthly anti-inflammatory tablet)
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