Dermatology Form

First Name*

Last Name*

Email *

Dermatology Questionaire

Your Name

Pets Name

Pets Age

Pets sex

Pets breed

When did you first notice the problem?

Do the symptoms seem worse during a certain time of year (ie. summer, winter, spring, fall)?

What did the problem look like when it 1st started(Itching, Hair loss, rash, pimples, redness, other)?

What area of the body did you first notice the problem ( face, abdomen, chest, back, tail base, ears, legs, paws)?

Has it seemed to spread? to where?

Did you notice your pet itching first?

Are there other pets in the house, and do they have any problems?

Do you have any skin problems? Explain

Do any people in your houshold have any skin issues? Explain

What percentage of time is your pet inside vs. outside?

Are symptoms worse in the morning? evening? inside?, outside?

Is your pet spayed or neutered?

If female and not spayed when was the last heat cycle?

If male and not neutered does he show interest in female dogs?

Does your pet have fleas?

Have you used any of the following? (Flea spray, Flea Dip, Flea Collar, Flea Powder, Baths, Any Insecticides)?When?

Have you noticed any other parasite problems ( Ticks, Mites, Lice, Flies)?

Do you use any insectacides in your house or yard? If so which ones?

Has your pet been out of their normal area ( ie. on vacation, abnormal places)?

What medications has your pet been on while this problem has occured?

Where these medications for the problem, and did they seem to help?

Do you give your pet suppliments, or vitamins? Which Ones?

What brand(s) of food does your pet eat? Wet or Dry?

Does your pet get table scraps?

Does your pet get treats? If so what kind(s)?

Has your pet been Coughing, Sneezing, Runny Nose? Runny Eyes, Vomiting, Diarrhea, Poor appetite, Excessive Appetite, Regular exercise, Worms, Been Shaking their head?

Has your pet had any other illnesses? Explain?

Is there anything else you would like the doctor to know?

Appointment Request

Location

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Perkins Veterinary Clinic

Address

11016 S Perkins Rd
Perkins, OK 74059, US

Contact Information (405) 547-2442

[email protected]