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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The most wonderful caring people. They saved my little boy's life from leptospirosis. I cannot thank them enough!
- Dee M.

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