Dermatology History Form - Yonge & St. Clair Veterinary Hospital

Why is it so tough to figure out what’s going on with your pet’s skin?

Unfortunately, many skin conditions look very similar, and the main presenting complaint in veterinary dermatology is itching. The cause of itching can range from hypersensitivities (allergies to food, environmental allergens, and insect bites) to immunemediated conditions and even cancer. This is why it is so important to visit your veterinarian early to figure out the cause of your pets’ itching and get them some relief

If your pet is itchy or you are concerned about their skin/ears, please schedule an appointment with your veterinarian soon. Before your visit complete this history tool with as much information as possible. This will help you and your veterinarian start the conversation and find a plan that is right for your best friend.

Name *

First

Last

Email *

Pets Name *

Age *

Breed *

Sex *

What are you most concerned about with your pet’s skin/ears? *

At what age were skin/ear problems/itching first noticed? *

The age of onset of your pet’s symptoms can give your veterinarian clues about what disease process or what type of allergy could be affecting your pet.

With a history of a rapid onset your veterinarian will consider things like ectoparasites, or possible adverse reactions to medications. Gradual onset of symptoms often indicates an underlying allergy. *

Rapid onset
Gradual onset

Does your pet itch? *

Yes
No

If you answered “Yes”, please select all that apply: *

If other, please specify

When? *

Constant
Sporadic
Night only

Rate your pet’s itching on a scale of 0 – 10: *

(0—no itching to 10—constant, severe itching all day and night)

What time of year is your companion most itchy? *

What parts of the body are most itchy? *

If other, please specify *

What other pets live in your household? Do any have skin problems or itching? *

What contact does your furry friend have with other pets (daycare/dog park/groomer)?�� *

Do any people in the house have skin problems or itching? *

Knowing if any other animals or humans are affected can help narrow things down to ectoparasites, mange or ringworm.

What proteins have you fed your pet in their lifetime including treats, food, table scraps and chew toys? *

The vast majority of pets with food hypersensitivities, have allergies to proteins. Please indicate which proteins you have previously fed your pet. Don’t forget about things like treats, flavoured medications, flavoured toothpaste and chew toys like bones and antlers. You may need to reach out to the pet food company for more info on the ingredient list, and bring a photo of your bag to your vet

How many bowel movements a day? *

Bowel movement consistency *

Small, hard, dry fecal balls
Log shape, easy to pick up with a scoop or bag
Semi-formed and mushy
Loose/Diarrhea

Is your pet on flea/tick/heartworm prevention? *

Yes
No

Name of product used

How often do you bathe your animal? What shampoo do you use?

Seasonal or Year-round

Seasonal
Year-round

What medication is your pet taking at this time including name and dose? *

Please include any nutritional supplements, and topicals such as ear drops or creams

Do all the pets receive the same flea/tick control at the same intervals? *

It’s important to know how your furry friend has responded to previous treatments. For example, a good response to corticosteroids (prednisone, prednisolone, dexamethasone) can indicate an environmental allergy or an immune-mediated skin disease, while a poor response can be seen with a food allergy.

What other health problems does your pet have? *

FOR YOUR APPOINTMENT • Be sure to bring the previous medications, pills, ointments, ear cleaners, shampoos, ingredient labels of food and treats. • Do not bathe your pet within 3 days, do not clean or treat ears within 2 days of your dog’s appointment.

Having a loved one suffer with being itchy is tough on everyone, so please help your veterinary care team help your furry friend by filling out the history questionnaire to the best of your ability