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Voor dierenartsen
Verwijzen
Spoed- en specialistenkliniek
Dermatologie
Allergiepoli
Dermatologiepoli
Orenpoli
Chirurgie
Interne geneeskunde
Maag-darm poli
Oogheelkunde
Orthopedie
Artrosepoli
Fysiotherapie
Radiologie
Spoedkliniek
Nascholing
Meeloopdag
MCDeelgenoot
Kennisbank
Teleconsult Internist
Voor huisdiereigenaren
Afspraak maken
Spoed- en specialistenkliniek
Chirurgie
Dermatologie
Allergiepoli
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Maag-darm poli
Teleconsult Internist
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Dermatologie Questionnaire Ear DOG
Stap
1
van
2
50%
Name owner
(Vereist)
Dog's name
(Vereist)
date of birth
(Vereist)
DD slash MM slash JJJJ
Breed
(Vereist)
Questions about the nature of the complaints
Your dog has complaints of
(Vereist)
make your choice
the right ear
the left ear
both ears
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)
make your choice
no
yes, on holiday
yes, was born abroad
In which countries has your dog been on holiday?
(Vereist)
Our dog originates from?
(Vereist)
Do you have other pets?
(Vereist)
make your choice
no
yes
What other pets do you have?
(Vereist)
Does your dog drink more than usual?
(Vereist)
make your choice
no
yes
Are there any changes in your dog's eating pattern?
(Vereist)
make your choice
no
yes; he/she eats less than usual
yes; he/she eats more than usual
Does your dog vomit sometimes?
(Vereist)
make your choice
no
yes; a few times a month
yes; a few times a week
has vomited in the past, but not anymore
Does your dog have diarrhea sometimes?
(Vereist)
make your choice
no
yes; a few times a month
yes; a few times a week
yes; a few times a day
has had diarrhea, but not anymore
Is your dog less active (age taken into account)?
(Vereist)
make your choice
no
yes
Does your dog have other (physical) complaints, except ear complaints?
(Vereist)
make your choice
no
yes
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.