Pre-Dermatology Appointment Questionnaire Pet NameClient NameDate Date Format: MM slash DD slash YYYY Reason for visit: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 possible9. If your pets ears are bothering them, is there swelling, odor or discharge?10. Is your pet licking their feet?YesNo11. 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.Client questions:1. Have you or anyone in your household had COVID19? If so, when?YesNoIf so, when?2. Have you or anyone in your household had any respiratory illness or other symptoms like loss of taste or smell in the past 2 weeks?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?