Pittsburgh Veterinary Dermatology

807 Camp Horne Rd
Pittsburgh, PA 15237

(412)366-3400

pittvetderm.com

New Patient Questionnaire Form

Client Name
First Name
Last Name
Spouse/Other Owner
First Name
Last Name
Address
Street Address
City
,
State / Province
Zip / Postal Code
E-Mail Address :
Home Phone
Phone TypePhone Number
Cell Phone
Phone TypePhone Number
Please tell us your preferred mode of communication. Text messages will be limited to appointment reminders only. Please note the best way to reach you during the day.

Please list all veterinary offices visited in the past 3 years. Please include phone number if available.

How did you hear about us?

Does your pet see any other service at PVSEC? If yes, please specify.

Patient Information
Patient Name

Species

Canine
Feline
Other


Breed

Sex

Male
Female
Neutered Male
Spayed Female


Birth Date (or estimate) :
Color/Markings

Are you this pet's owner?

Yes
No


How old was your pet when you got him/her?

Where did you obtain this pet?

Breeder
Shelter
Pet Shop
Other


Has this pet ever lived/visited outside your current geographical area?

Yes
No
Unknown


What percentage of the time does your pet spend indoors or outdoors?
% Indoors

% Outdoors

Does your pet go to a boarding kennel

Yes
No


If yes, how often?

Does your pet go to the groomers?

Yes
No


If yes, how often?

Please briefly list any known health problems OTHER than skin/ear disease:

Please list any medications given to this pet for problems OTHER than skin disease:

Patient History
What dermatological problem are you bringing your pet in for?

How long has the problem been present?

How old was your pet when the problem first started?

When the problem first started, did it come on:

Suddenly
Gradually over a period of time


Does your pet have any of the following?
Cough
Runny Eyes
Diarrhea
Constipation
Loss of Appetite
Excessive Urination
Sneezing
Ear Infections
Vomiting
Excessive Drinking
Limping
Weight Loss
Weight Gain
If you checked any of the above, please list frequency and description:

Which would you say best describes the progression of your pet's skin problem?
I first noticed a skin rash or hair loss which does not seem to bother my pet.
I first noticed a skin rash or hair loss and afterwards some itching developed (chewing, biting, scratching, rubbing, or licking)
I first noticed some itching (chewing, biting, scratching, rubbing, or licking) before any hair loss/rash
If your pet is itchy (chewing, biting, scratching, rubbing, or licking), please answer the following questions:
Does your pet scratch, rub, lick, chew, or bite any of the following areas?
Nose/Muzzle
Eyes
Back Paws
Front Paws
Chest
Back
Front Legs
Back Legs
Tail
Abdomen
Rump
Ears
Armpits
Inner Thighs and Legs
Other
Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease? On a scale of 1-10, how severe is the itching? (1=slight, 10=severe/constant, keeps you awake at night, stops normal activity to scratch)

How itchy has your pet been over the last month? On a scale of 1-10, how severe is the itching? (1=slight, 10=severe/constant, keeps you awake at night, stops normal activities to scratch)

How frequent it the itching? :
Is the problem year-round?

Yes, it has always been year-round
Yes, but it used to be seasonal (only part of the year)
No
Unknown


If seasonal, which time of year is the problem present or more severe?
Spring
Summer
Fall
Winter
Medication History
Please list ALL medications your pet is currently taking for their skin and ear disease (Include supplements and treatments that are over-the-counter).
Please bring all the medications, supplements or topical treatments that you use to your appointment if possible.
Please list Name of medication, dose of medication (if known), how long your pet has been receiving the treatment, are they currently being used, when was the last dose given.

Did any of the medications help the problem? If so, which ones?

Is your pet receiving fatty acids? Please list brand if known.

Please list any topical therapies such as ear cleaners and/or medications, topical sprays, lotions, wipes, ointments/creams:

Is your pet on allergy vaccine?

Yes
No


Diet
How many bowel movements does your pet have per day?

Has your pet been treated for stomach or intestinal problems? If yes, please explain.

What brand and flavor of diet do you feed your pet currently?

What treats are provided (biscuits, rawhide/pig ears, hooves, bones, table food)?

Do you brush your pet's teeth? If yes, what flavor is the toothpaste?

If using an oral medication, is it flavored?

Yes
No
Don't Know


Is your pet receiving medication for arthritis/joint problems?

Yes
No
Don't Know


If yes, which one(s)?
Chondroitin Sulfate
Glucosamine
Etogesic
Rimadyl
Deramaxx
Metacam
Other
Are the supplements/medication that you are using flavored? If yes, list flavor(s) if known.

Have you ever done a strict food trial (nothing besides the prescription diet and approved treats were fed during the food trial) using only a prescription diet prescribed by your veterinarian? If yes, what food was fed?

Bathing
How often do you usually bathe your pet?

When was the last time you bathed your pet?

Can you bathe your pet?

Yes
No


Where do you bathe your pet?
At home
At a self service dog wash
Groomer
What shampoo do you use?

Do you have a medicated shampoo prescribed to you by your veterinarian? If so, please list which ones and bring them to your appointment.

Do you think bathing your pet is helpful?
Yes
No
Flea Control
Do you routinely use flea control?

Yes
No


If yes, which one is used?
Advantage - topical
Frontline/Frontline Plus - topical
K9 Advantix - topical
Revolution - topical
Hartz/Biospot/Other OTC topical spot-on
Parastar/Parastar Plus
Comfortis
Trifexis
Bravecto
Nexgard
Simparica
Credelio
Capstar
Seresto Collar
Other
How often is flea/tick control applied/given to this pet?

How often is it applied to other pets in the household?

When was the last time you saw a flea on your pet?

When was the last time you saw a flea on other pets or on in-contact animals?

Miscellaneous Information
Do you own any other pets? If yes, what kind?

Are the other pets:

Indoors
Outdoors
Both


Is there exposure to other animals outside your household? If yes, what kind?

Do other animals or people in the house have lesions/itching? If yes, who?

Do you know if any litter mates or the parents of this pet have similar skin problems?

Do you or any family member work in the healthcare field? If yes, what is the occupation?

Routine Care
Is your pet up to date on vaccinations?

Yes
No
Don't know


For Dogs:
Is your pet receiving heartworm prevention? :
If yes, which brand?
Heartgard
Interceptor
Sentinel
Sentinel Spectrum
Revolution
Trifexis
Other
Has your pet been tested for heartworm disease in the past 12 months?

Yes
No
Don't know


For Cats:
Has your pet tested negative for Feline Leukemia Virus (FeLV) and Feline Immunodeficiency Virus(FIV or Feline AIDS)?

Yes
No
Don't Know


When was the last test done?

Are there any other symptoms that your pet has that have not been described above, or is there anything else you think might be contributing to your pet's skin or ear disease?


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