Pre-Dermatology Appointment Questionnaire in Leaburg, OR

Pet Name

Client Name

Date

1. Is your pet on flea, tick, and heartworm medications? If yes, what brand?

2. Is your pet on any prescriptions or supplements?

3. What type of food is your pet eating?

4. What treats or table food does your pet eat?

5. Has the pets diet changed recently? If yes, what was the previous diet?

6. Are your pets ears, skin, or both bothering them?

7. When did the symptoms start?

8. Please describe your pets' symptoms. Both affected areas and appearance if possible

9. If your pets ears are bothering them, is there swelling, odor or discharge?

10. Is your pet licking their feet?

11. Are any other pets in the household affected?

12. What medications if any is your pet currently on? Any supplements?

13. Is this a recurring problem? Have you noticed any patterns like time of year, diet response etc.

1. Have you or anyone in your household been exposed to Covid-19 within the past 10 days?

If so, when?

2. Have you or anyone in your household had any respiratory illness within the past 10 days?

3. What is the best phone number to reach you at?

Is there anything else you’d like us to be aware of regarding your pet or yourself?

Which type of appointment would you prefer?

Pre-Dermatology Appointment Questionnaire