Russell Vale Animal Clinic

17 Bellambi Lane
Bellambi, NS 2518

(024)284-5988

www.animalclinic.com.au

Skin History Questionnaire 

Source - This is a modified version of the Skin History Questionnaire from Blackmores. 

Please fill this out and submit it prior to your veterinary consultation at Russell Vale Animal Clinic (whether Email Dr Liz, Virtual Dr Liz or the Real Dr Liz).  

Thanking you.



About you and your pet
Owner's Name
Owner's Address
Phone number
Email address (all information will be emailed to this address)
Pet's name
Dog /Cat/ Other
Breed
Age or date of birth
Sex (male/male desexed/Female/Female desexed

Skin Questions
What is the main problem?
How long as the problem been present? Days, weeks, months or years
Is there a history of skin disease previous to this?
Where on the body was first affected?
What came first - the itch or the rash/hairloss?
What time of year did the problem begin? Spring Summer Autumn Winter
When is the skin problem present? All year round or Intermittent or Seasonal?

What did the affected area first look like ? Specify Y or N
Red/inflamed
Scurf/Dandruff
Scabs/Crusts
Hair Loss
Other
Is your pet itchy?
If itchy, the degree of itchiness

Does he/she rub or scratch
Face Belly Armpits Lick/chew/nibble feet Shake head Bottom Legs Rub/bitedrag the lower back/tail base . Other pls specify

Other information
Does your pet have any history of ear problems? Yes/No
Where does your pet spend most of its time - only indoors, only outdoors, mostly indoors, mostly outdoors, both indoors and outdoors?
Where does your pet sleep?
Does your pet go for regular walks? Y/N
Live near bushland? Y/N
Visit Parks Y/N
Do you notice the issue worsening when your pet encounters a particular environment? such as grass, freshly mown lawn, other?
What do you use for regular flea control, and when was it last applied.
Do you bath your pet? If so, what do you use? Did you find it helped, not helped or made no difference?
Do you use a conditioner on your pet? If so, what?
Please list any previous treatments used for your pet's skin problem, and note whether they helped or did not help. Also note any side effects.

Miscellaneous questions
What do you feed your pet?
Has your pet ever been on a special diet? If so, what was it and did it help?
Any history of chronic bowel upsets (diarrhea and or vomiting?
Does your pet have any other health problems?

Has there been any recent change to..... (answer Y or N)
Appetite Y or N
Energy Level Y or N
Thirst Y or No (if an increased thirst, pls bring in a urine sample if possible)
Any other comments?

We thank you for taking the time to answer all of these questions. Email or FB messenger photos of your pet's skin. We look forward to helping you and your pet. Don't forget to press the "Submit button" below.
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