Dermatology and Allergy Service Questionnaire

First Name*:

Last Name*:

Email Address*:

NorthStar VETS Location:

Robbinsville     Maple Shade

Patient Name*:

Pets Age*:  

Type:   Dog    Cat   


Gender:   Female   Male   

Neutered? Yes    No   

How did you hear about the Dermatology Service?

Describe your pet's skin problem. (Check all that apply):

Scratching, chewing, licking, rubbing skin
Ear infections
Hair Loss with itching
Hair Loss without itching
Red Bumps, pimples,scabs
Excessive dandruff, scaling
Skin odor, greasiness
Nail infections or nail loss

Was itching the first sign of your pet's skin disease that you noticed?   Yes    No   

How long has your pet had this skin and/or ear problem?

Please specify days/weeks/months/years

Was the problems's onset gradual or onset?   Gradual    Sudden   

On a scale of 1-10 with 1=occasional chewing or scratching and 10=severe constant scratching that keeps you up at night, how would you rate your pet's level of itchiness now?

Was itching the first sign of your pet's skin disease that you noticed?   Yes    No   

Describe how the skin problem first appeared and how it changed over time.

What areas of your pet are affected? (Check all that apply)

Rump/tail area
Groin/inner thighs
Anal/genital area

Has your pet always lived in this part of the country?    Yes    No   

Has your pet ever traveled to other countries?    Yes    No   
If yes, please list the dates of travel.

Is/are your pet's problem(s) intermittent or continual?    Intermittent    Continual   

Is there currently a relationship between your pet's problem(s) and the season of the year?    Yes    No   

If yes, please check the season(s) when the problem is worse.


The problem begins in:

Do you have any other pets?    Yes    No    Does Not Apply   
If yes, please list all other pets.

Do your other pets have similar skin conditions?    Yes    No   
If yes, what are the other pet's problems?

Has any person in your household had skin problems since your pet
started having skin problems?   Yes    No

If yes, please describe.

Have you noticed fleas on your pet recently?    Yes    No   

Are you currently using flea products?    Yes    No   

If yes, list the products:

Is your pet exposed to other animals or wildlife (dog parks, boarding, groomer, woods)?    Yes    No   

If yes, what kind?

What treatment has your pet received for his/her skin problem?

         Please list:
Antifungals e.g. ketoconazole, fluconazole
Oral cortisone e.g.: prednisone, Vetalog, dexmethasone
Cortisone/steroid injections
Antihistamines e.g.: Benadryl, atarax, chlorpheniramine
Fatty Acids/oils, fish oil capsules, Derm caps, vegetable oils
Ivermectin (anti-mite injections)
Ear ointments or drops
         Please list:
Herbal or homeopathic remedies
         Please list:

Describe what response there was to this treatment?

Did medication help your pet's problem(s)?    Yes    No   

If yes, which medication was the most effective?

What medications are your pet presently receiving and when was it last given?

Do you bathe your pet?     Yes    No   

If yes, how often?

What is the name of the shampoo?

Do you clean your pets ears? Yes    No   

If yes, how often?

What is the name of the ear cleaner?

Does your pet have any other previously diagnosed medical or surgical problems unrelated to the skin disorder? Yes    No   

If yes, please describe

Is your pet recieving any medication for this disorder?    Yes    No   

If yes, please list medications

Have you noticed any change in the health or behavior of your pet that coincided with the development of the skin condition? (e.g. changes in food or water intake, changes in urination or defecation, changes in activity level?)    Yes    No   

If yes, please list

Describe the current diet of your pet including brand names and any table foods, treats, biscuits, vitamin supplements, or rawhide chews given?

Has your pet ever been on a special food elimination diet?    Yes    No   

If yes, what commercial brand of food or home-cooked diet ingredients were used and for how long?

For Dogs: Is your pet currently on heartworm preventative (Heartguard, Interceptor, Sentinel, Revolution)?

Yes    No   

If yes, is it chewable?    Yes    No   

For Dogs: Has your pet been blood tested for heartworm disease within the last 6 months    Yes    No

For Cats: Has your cat tested negative for Feline Leukemia(FeLV) and Feline Immunodeficiency Virus (FIV or feline AIDS virus)    Yes    No