Dermatologie questionnaire DOG - Medisch Centrum Voor Dieren

Dermatologie questionnaire DOG

Stap 1 van 7

Name owner(Vereist)

Dog's name(Vereist)

date of birth(Vereist)

Breed(Vereist)

Questions regarding medication your dog has been given to treat skin- and/or earproblems:

Is your dog currently on any medication?(Vereist)

no

yes

Yes, my dog is currently on the following medication(Vereist)

Which medication has been administered to treat the skin related problems and what was the effect. Please, try to be as detailed as possible, meaning when, for how long and how many tablet s etc. The veterinarian’s referral letter might be of help.

Which medication at home has been administered to treat the skin related problems and what was the effect.

Name From and until when given Effect

Please, try to be as detailed as possible, meaning when, for how long and how many tablet s etc. The veterinarian’s referral letter might be of help.

Medication 2

Name From and until when given Effect

Please, try to be a detailed as possible, meaning; when, for how long and how mane tablets etc. The veterinarian’s referral letter might help.

Medication 3

Name From and until when given Effect

Please, try to be a detailed as possible, meaning; when, for how long and how mane tablets etc. The veterinarian’s referral letter might help.

Shampoos, ointments etc.

Name From and until when given Effect

Please, try to be a detailed as possible, meaning; when, for how long and how mane tablets etc. The veterinarian’s referral letter might help.

Shampoos, ointments 2

Name From and until when given Effect

Please, try to be a detailed as possible, meaning; when, for how long and how mane tablets etc. The veterinarian’s referral letter might help.

Shampoos, ointments 3

Name From and until when given Effect

Please, try to be a detailed as possible, meaning; when, for how long and how mane tablets etc. The veterinarian’s referral letter might help.

Medication administered by your veterinarian (injections etc.)

Name From and until when given Effect

Which medication has been administered to treat the skin related problems and what was the effect. Please, try to be as detailed as possible, meaning when, for how long and how many tablet s etc. The veterinarian’s referral letter might be of help.

Medication administered by your veterinarian (injections etc.) 2

Name From and until when given Effect

Please, try to be a detailed as possible, meaning; when, for how long and how mane tablets etc. The veterinarian’s referral letter might help.

Medication administered by your veterinarian (injections etc.) 3

Name From and until when given Effect

Please, try to be a detailed as possible, meaning; when, for how long and how mane tablets etc. The veterinarian’s referral letter might help.