Dermatologie Questionnaire Ear DOG - Medisch Centrum Voor Dieren

Dermatologie Questionnaire Ear DOG

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Name owner(Vereist)

Dog's name(Vereist)

date of birth(Vereist)

Breed(Vereist)

Questions about the nature of the complaints

Your dog has complaints of(Vereist)

Since when has your dog been showing these problems/complaints?(Vereist)

How old was your dog when these complaints started?(Vereist)

Has your dog been abroad?(Vereist)

In which countries has your dog been on holiday?(Vereist)

Our dog originates from?(Vereist)

Do you have other pets?(Vereist)

What other pets do you have?(Vereist)

Does your dog drink more than usual?(Vereist)

Are there any changes in your dog's eating pattern?(Vereist)

Does your dog vomit sometimes?(Vereist)

Does your dog have diarrhea sometimes?(Vereist)

Is your dog less active (age taken into account)?(Vereist)

Does your dog have other (physical) complaints, except ear complaints?(Vereist)

yes my dog has other physical problems(Vereist)

What medications did your dog get for the ear complaints and can you indicate the effect of this?

Name From and until when given Effect

Please indicate as accurately as possible, including when, how long and how many tablets etc. If your veterinarian has provided you with a file, you can consult this if necessary.

Medication 2

Name From and until when given Effect

Please indicate as accurately as possible, including when, how long and how many tablets etc. If your veterinarian has provided you with a file, you can consult this if necessary.

Medication 3

Name From and until when given Effect

Please indicate as accurately as possible, including when, how long and how many tablets etc. If your veterinarian has provided you with a file, you can consult this if necessary.

Shampoos, ointments etc.

Name From and until when given Effect

Please indicate as accurately as possible, including when, how long and how many tablets etc. If your veterinarian has provided you with a file, you can consult this if necessary.

Shampoos, ointments etc. 2

Name From and until when given Effect

Please indicate as accurately as possible, including when, how long and how many tablets etc. If your veterinarian has provided you with a file, you can consult this if necessary.

Shampoos, ointments etc. 3

Name From and until when given Effect

Please indicate as accurately as possible, including when, how long and how many tablets etc. If your veterinarian has provided you with a file, you can consult this if necessary.

Medication administered by your veterinarian (injections etc.)

Name From and until when given Effect

Please indicate as accurately as possible, including when, how long and how many tablets etc. If your veterinarian has provided you with a file, you can consult this if necessary.

Medication administered by your veterinarian (injections etc.) 2

Name From and until when given Effect

Please indicate as accurately as possible, including when, how long and how many tablets etc. If your veterinarian has provided you with a file, you can consult this if necessary.

Medication administered by your veterinarian (injections etc.) 3

Name From and until when given Effect

Please indicate as accurately as possible, including when, how long and how many tablets etc. If your veterinarian has provided you with a file, you can consult this if necessary.