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Voor dierenartsen
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Spoed- en specialistenkliniek
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Dermatology questionnaire ear cat
Stap
1
van
4
25%
Name owner
(Vereist)
Cat’s name
(Vereist)
date of birth
(Vereist)
DD slash MM slash JJJJ
Breed
(Vereist)
Questions about the nature of the complaints
Your cat has complaints of
(Vereist)
make your choice
the right ear
the left ear
both ears
Since when has your cat been showing these problems/complaints?
(Vereist)
How old was your cat when these complaints started?
(Vereist)
Do you have other pets?
(Vereist)
make your choice
no
yes
What other pets do you have?
(Vereist)
Has your cat been abroad?
(Vereist)
make your choice
no
yes, on holiday
yes, was born abroad
In which countries has your cat been on holiday?
(Vereist)
Our cat originates from?
(Vereist)
Does your cat vomit sometimes?
(Vereist)
make your choice
no
no, but has in the past
yes, occasionally
yes often
Does your cat have diarrhea sometimes?
(Vereist)
make your choice
no
no, but has in the past
yes, occasionally
yes often
Does your cat have other (physical) complaints, except ear complaints?
(Vereist)
make your choice
no
yes
yes my cat has other physical problems
(Vereist)
Do you treat your cat (and other pets) with anti-flea products?
(Vereist)
make your choice
no
yes, when I notice fleas
yes, but only during summer
yes, regularly throughout the year
which product(s) do you use?
(Vereist)
Does your cat go outside?
(Vereist)
make your choice
no
yes, but only on terrace/balcony
yes, on a regular basis; suburban area/city/country side
Did your cat follow a special diet for his/her earproblems?
(Vereist)
make your choice
no
yes, of a particular brand
yes, home cooked diet
Which diet food did you use? Note brand and type
(Vereist)
This self-cooked diet, this consisted of?
(Vereist)
Did you give other things during this diet such as snacks (vegetables/fruit), cookies, bones?
(Vereist)
make your choice
no
yes
We gave extras like
(Vereist)
How long has your cat been on this diet?
(Vereist)
Did the skinproblems improve?
(Vereist)
Which medication has been administered to treat the ear 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.
Medication 1
Name
From and until when given
Effect
Medication 2
Name
From and until when given
Effect
Medication 3
Name
From and until when given
Effect
Shampoos, ointments etc.
Name
From and until when given
Effect
Shampoos, ointments etc. 2
Name
From and until when given
Effect
Shampoos, ointments etc. 3
Name
From and until when given
Effect
Medication administered by your veterinarian (injections etc.)
Name
From and until when given
Effect
Medication administered by your veterinarian (injections etc.) 2
Name
From and until when given
Effect
Medication administered by your veterinarian (injections etc.) 3
Name
From and until when given
Effect
