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Voor dierenartsen
Verwijzen
Spoed- en specialistenkliniek
Dermatologie
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Dermatologiepoli
Orenpoli
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Maag-darm centrum
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MCDeelgenoot
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Dermatology questionnaire ear dog
Stap
1
van
4
25%
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
no, but has in the past
yes, occasionally
yes, often
Does your dog have diarrhea sometimes?
(Vereist)
make your choice
no
no, but has in the past
yes, occasionally
yes, often
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)
Do you treat your dog (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 anti-flea products
(Vereist)
Did your dog 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 dog been on this diet?
(Vereist)
Did the earproblems improve?
(Vereist)
Which medication has been administered to treat the ears 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, ointments etc. The veterinarian’s referral letter might be of help. Which medication at home has been administered to treat the ear 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
