PLEASE LIST ANY PEOPLE (OTHER THAN YOUR FAMILY VETERINARIAN) THAT ARE AUTHORIZED TO MAKE HEALTH CARE DECISIONS FOR YOUR PET OR HAVE ACCESS TO YOUR PET'S RECORDS:

WHO IS YOUR FAMILY VETERINARIAN?

Doctor:

Clinic:

Address:

City/Town:

Postal Code:

Phone:

Fax:

PLEASE NOTE:

Do not bathe your pet for at least 5 days prior to your appointment and do not feed your pet for at least 12 hours prior to your appointment (UNLESS OTHERWISE SPECIFIED BY YOUR VETERINARIAN),
In most cases, pets will not be allergy tested at the first visit. As a general rule of thumb, prior to allergy testing, pets may not receive any oral steroids for at least 28 days, injectable steroids for a minimum of 2-3 months, topical (eye, ear and skin) steroids for at least 14 days, and antihistamines, fatty acids and high fatty acid diets for at least 14 days. Longer withdrawal times may be recommended on a case by case basis.
Initial consults can take 90 minutes, please be sure to schedule your time accordingly.
Please refrain from allowing animals to "socialize" with one another in the waiting room
Please note that animals referred to our facility can only be treated for skin related disorders. All other unrelated treatments or procedures will be conducted by your family veterinarian.
Payment is due at the time of appointment. We accept cash, interac, visa, and mastercard. Unfortunately, we cannot accept cheques. Missed appointments are subject to a cancellation fee unless notified 24 hours or more in advance.
Please bring along any remaining medications that you may have used for your pet’s skin problems

AS THERE ARE MANY CONDITIONS IN DERMATOLOGY THAT LOOK THE SAME, PLEASE TAKE THE TIME TO ANSWER ALL QUESTIONS AS FULLY AS POSSIBLE. THE HISTORY OFTEN GIVES US MORE CLUES AS TO THE CAUSE OF THE DISEASE THAN THE CHECKUP! PLEASE CHECK THE APPROPRIATE BOX (WHERE APPLICABLE)

GENERAL PET DATA

1. Pet's Name:

2. Pet's Birth Date or approximate age:

3. Species: Dog Cat Other (explain):

4. Breed:

5. Sex: Male Female

6. Neutered (castrated or spayed?): Yes No

7. Colour:

8. Approximate weight: Kilograms Pounds

9. Age first obtained:

10. Where was your pet obtained?
Kennel/Breeder Pound/Humane Society Pet Store
Advertisement Friend Stray
Other (Please explain:)

GENERAL HEALTH

11. I would describe my pet's activity level as:
Normal Lethargic Hyperactive

12. I would describe my pet's water intake as:
Normal Increased Decreased

13. I would describe my pet's appetite intake as:
Normal Increased Decreased

14. Urination:
I would describe my pet's urine volume as:
Normal Increased Decreased
and the frequency as:
Normal Increased Decreased

15. Any coughing/sneezing/trouble breathing? No Yes
If YES, please describe:

16. Are you aware of any significant non dermatological medical problems in your pet? No Yes
If YES, please describe:

ENVIRONMENT

17. Where does your pet stay?
Primarily Indoor Primarily Outdoor In/Out
Other (Please explain:)

My pet prefers the following types of places:
Warm Cold No Preference

18. If INDOORS, where does your pet spend most of its time?

19. If OUTDOORS, where does he/she come in contact with?

20. What do you feed your pet (including treats)?

21. Have there been any changes in the diet? No Yes
If YES, when and how has the diet changed?

CONTAGION

22. Are there any other pets in the household? No Yes
If YES, please list type(s) of pet(s):

Do they have any skin problems? No Yes
If YES, please describe:

23. Does your pet's parents or litter mates have any history of skin problems? Unknown No Yes
If YES, please describe:

24. To the best of your knowledge, has your pet been in contact with any other pets with skin problems? No Yes

25. Has your pet been travelling? No Yes
If YES, please explain where and when:

26. Do you board your pet? No Yes
If YES, when was the last time?

27. Do you take your pet to a grooming studio?: No Yes
If YES, when was the last time?

28. Have any people in the home, including visitors, developed any skin problems since your pet has had problems? No Yes
If YES, please describe:

PRESENTING COMPLAINT

29. My pet's major skin problem is:
Itchiness    Hair Loss    Sores
Lumps/Bumps    Ear problems    Claw disease
Colour change    Other (please explain)

Are there other problems that concern you? If so please describe:

30. At what age did the problem first begin?

31. If multiple problems, what did you notice first?

32. Was the onset sudden or gradual? Sudden Gradual

33. Where on the body did the problem started?

34. If there were sores, what did they look like at first?

If it has since changed, how has it changed?

35. Was the pet itchy before the sores came? No Yes

36. Is the problem INTERMITTENT (comes & goes)
or CONTINUAL (never stops without treatment)? Intermittent Gradual

If Intermittent (comes & goes): did you notice the problem occurring at any specific time of year? No Yes

If YES, please mark the months below:

Jan	Feb	Mar	Apr	May	Jun
Jul	Aug	Sep	Oct	Nov	Dec

If Continual (never stops without treatment):

Did it start intermittently? no yes

If YES, please mark the months below:

Jan	Feb	Mar	Apr	May	Jun
Jul	Aug	Sep	Oct	Nov	Dec

Are there times of the year that the conditions worsens?
no yes

If YES, please mark the months below:

Jan	Feb	Mar	Apr	May	Jun
Jul	Aug	Sep	Oct	Nov	Dec

37. Does your pet lick, scratch, rub, bite, chew or overly groom him/herself?
no yes

If NO, please go to question 38

If YES, Please rate the discomfort from
0 (not at all), 1 (mild) to 5 (severe) in the chart below.

Eyes	0 1 2 3 4 5
Ears	0 1 2 3 4 5
Face	0 1 2 3 4 5

Muzzle	0 1 2 3 4 5
Neck	0 1 2 3 4 5
Front Paws	0 1 2 3 4 5

Front Legs	0 1 2 3 4 5
Back Legs	0 1 2 3 4 5
Back Paws	0 1 2 3 4 5

Claws	0 1 2 3 4 5
Chest	0 1 2 3 4 5
Sides	0 1 2 3 4 5

Armpits	0 1 2 3 4 5
Belly	0 1 2 3 4 5
Groin area	0 1 2 3 4 5

Back	0 1 2 3 4 5
Back near tail	0 1 2 3 4 5
Tail	0 1 2 3 4 5

Anus	0 1 2 3 4 5
Penis/vulva	0 1 2 3 4 5
Other:	0 1 2 3 4 5

Is the front half or back half the itchiest?
Front Back Unsure

38. Would you describe your pet as scaly (lots of dandruff) or greasy?
No Yes unsure

If YES, is your pet Scaly Greasy Both

Is it mild, moderate or severe? Mild Moderate Severe

At what age did the scaling/greasiness begin?

39. Would you describe your pet as malodourous (smelly?)
No Yes If NO, go to 40.

If Yes, does it go away after bathing?
No Yes

If bathing helps, how soon after a bath does it return?

40. Does your pet suffer from hair loss? No Yes
If YES, at what age did the hair loss start?

Are there bald patches or just thinning of the coat?
Bald Thin Coat Both
Where is the hair loss prominent?

41. Does your pet have any bumps or pimples? No Yes
If YES, where are they located?

If multiple bumps and pimples, where did they start?

Did they look different in the beginning?
No Yes If YES, please explain:

42. Does your pet have any rash or discolouration of the skin, hair or claws? No Yes If YES, please explain:

At what age did you first notice it?

Where did it start?

TREATMENT HISTORY

43. Did your pet improve while on any medication?
No Yes If YES, which medicine (s) worked:

44. Please check any applicable boxes: While my pet was getting the treatment,

The Itchiness:
Resolved
Resolved at higher dosages but recurred as I lowered the dose.
Improved but never went away.
Remained
Worsened with what treatment:

The Sores/Rash:
Resolved
Resolved at higher dosages but recurred as I lowered the dose.
Improved but never went away.
Remained
Worsened with what treatment:

The Hair Loss:
Resolved
Resolved at higher dosages but recurred as I lowered the dose.
Improved but never went away.
Remained
Worsened with what treatment:

The Lumps:
Resolved
Resolved at higher dosages but recurred as I lowered the dose.
Improved but never went away.
Remained
Worsened with what treatment:

Other (please explain):

45. Is this statement true?
The Itchiness Hair Loss Bumps and/or Sores completely resolved, only to relapse after the treatment was stopped.

No Yes If YES, how long after discontinuation?

46. Is your pet currently receiving any medication? No Yes
If YES, please list which medicine (s), the dose and frequency (how often), if known. worked:

47. When was your pet last bathed? (Please remember not to bathe for at least 5 days prior ot the appointment)

48. Has your dog had a heartworm test this year? No Yes
If YES, what was the result?

Is your pet currently on heartworm prevention medication? No Yes

49. Has your pet been on flea prevention/treatment?
No Yes If YES, when?

Which ones (s) if known?

50. Does your pet have any known sensitivities to medications or sedatives?
No Yes If YES, which ones (s) if known?

51. Does your pet suffer from any seisure or seizure like disorders?
No Yes

52. Can you
Bathe your Pet?    No    Yes
Administer drops, lotions or creams?    No    Yes
Administer tablets / capsules?    No    Yes
Administer oral liquids?    No    Yes

53. Your opinion is very important to me. What do you think the problem may be?

Both sections A and B must be returned to our hospital at least 24 hours prior to your appointment. Completed forms can be sent by:

Faxed to: 416-920-6185, or Mailed to the
DERMATOLOGY DEPARTMENT, VETERINARY EMERGENCY CLINIC
920 YONGE STREET, SUITE 117, TORONTO, ONTARIO, M4W 3C7

Please be sure to have your regular veterinarian complete section B, submitting either the
Section B, on-line version, or
Section B, fax version. (Pages 12 to 14 of the document)

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