Please fill out our New Patient Dermatology Questionnaire using one of the options below if your pet is a new patient at AnimERge in Somerset County.

OPTION 1
Complete Online

Complete and submit the form below.

OPTION 2
Print & Complete

Bring the completed form with you.

Download Form

OPTION 3
Complete on Arrival

If you prefer, you can complete the form when you get to our hospital.

Dermatology Questionnaire

Please provide us with the following information.

Client First Name *

Client Last Name *

Email *

Phone *

Referring Veterinarian

Was your pet referred by your veterinarian? *

Did you request for records to be faxed? *

Has your pet seen a veterinary dermatologist in the past? *

If yes, name of hospital

If yes, name of veterinary dermatologist

Patient Information

Patient Name *

Where did you get your pet? *

How long have you had your pet? *

Patient History

Please list any underlying diseases / conditions. *

What is the primary reason for today's visit? *

Age when the problem was initially noticed

How many days, years or months have you noticed the problem? *

Does there seem to be a seasonal influence? *

If yes, which season?

Travel History / Recent Move? *

Does your pet experience any of the following? *

Vomiting

Diarrhea

Coughing

Sneezing

Tiredness / Lethargic Behavior

Hyperactive Behavior

Lameness

How would you describe your pet's weight? *

How would you describe your pet's urination? *

How would you describe your pet's drinking behavior? *

How would you describe your pet's appetite? *

Please check off any of the following clinical signs that pertain to your pet *

Itching

Licking / Chewing

Flaky Skin (Dandruff)

Red Skin

Thick Skin (Elephant Skin)

Malodorous Ears

Bumps (Pustules or Papules)

Swollen Feet (Between Toes)

Curving / Cracking / Breaking Nails

Hair Loss (Alpecia)

Welts (Urtcaria / Wheals)

Draining Lesions

Other

If other, please specify.

Where do the lesions start? (back, belly, groin, feet, ears, face, etc.) *

Describe the onset of the disease / lesions (gradual, sudden, etc.) *

What did the lesion intially look like? *

Where are the lesions most severe? *

Do any of your other pets have similar skin conditions? *

If yes, who?

If your pet itches, on a scale of 1 to 10 how sever is the itching? (1-slight, 10-severe)

How frequent is the itching?

When is the itching worst?

What percentage of time does your pet spend indoors? *

What percentage of time does your pet spend outdoors? *

Describe what your pet sleeps on (pet's bed, owner's pet, feather bed, wool, outdoors, etc.) *

Vaccinations

What vaccinations has your pet had (Rabies, DHLPP, FVRCP, etc.), and when were they last administered? *

Diagnostics

What diagnostics tests have already been performed? (eg. Blood tests - CBC, chemistry, thyroid panel, ACTH stimulation; Allergy Testing - serology, skin testing, diet testing; Skin or ear cytology)

Diet

What is your pet's current diet? (canned, kibble, brand, etc.) *

Have you tried a special diet? *

If yes, which diet(s)?

If yes, does / did the diet seem helpful?

What types of treats do you give your pet? (biscuits, rawhide / pig ears, hooves, bones, table good, etc) *

Do you brush your pet's teeth? *

If yes, what flavor is the toothpaste?

Medication

Is your pet receiving heartworm prevention? *

If yes, which brand? (eg. Heartgard, Iverhart, Interceptor, Sentinel, Revolution-topical)

If using an oral medication, is it flavored?

Is your pet receiving medication for arthritis / joint problems? *

If yes, which one? (eg. chondroitin sulfate, NSAIDA Etogesic, Rimadyl, Deramaxx, Metacam)

If yes, are these flavored? *

If yes, what flavor?

Have treatments been tried for skin or eat diseases / allergies? *

For any of the following, please indicate dose, route, duration and if currently being used. Include treatments that are over the counter.

Antihistamines

Corticosteroids (Oral or Injectible?)

Antibiotics / Anti-yeast

Essential Fatty Acids

Topical Therapy

Other (eg. allergy shots, natural supplements)

Flea / Tick Prevention

If flea / tick prevention, which brand?

Bathing & Swimming

Last time bathed *

Frequency of bathing *

Product(s) used

Bathing location (eg. groomer, home, self-dog wash) *

Swimming *

Yes

Ocean

River

Lake

Frequency of swimming

Please provide any other information you feel may be helpful including frequency of use, last date used / applied (eg. shampoo, ointments, creams, ear infections)

Any other information you'd like to share?

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Happy Tails from Clients

My dog was very sick when I brought him in. The doctors, vet techs and receptionists were wonderful to him and to me. All the doctors were great and went above and beyond to help my little guy get better. After a week of treatment and great care he came home and is doing so well!
- Janet K.

Dermatology Questionnaire

OPTION 1Complete Online

OPTION 2Print & Complete

OPTION 3Complete on Arrival

Dermatology Questionnaire

Referring Veterinarian

Patient Information

Patient History

Vaccinations

Diagnostics

Diet

Medication

Bathing & Swimming

Caring for Pets in Somerset County

OPTION 1
Complete Online

OPTION 2
Print & Complete

OPTION 3
Complete on Arrival