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Voor dierenartsen
Verwijzen
Spoed- en specialistenkliniek
Dermatologie
Allergiepoli
Dermatologiepoli
Orenpoli
Chirurgie
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Maag-darm poli
Oogheelkunde
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Artrosepoli
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MCDeelgenoot
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Dermatology questionnaire dog
Stap
1
van
7
14%
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
What complaints does your dog show?
(Vereist)
make your choice
skinproblems/itchiness
earproblems
both skinproblems as well as (occasional) earproblems
Since when has your dog been showing these problems/complaints?
(Vereist)
How old was your dog when these problems began?
(Vereist)
Does your dog show any signs of itchiness?
(Vereist)
make your choice
no
yes, minor itchiness
yes, severe itchiness
indicate where on the body the itching occurs
General health/physical condition:
Does your dog drink more than usual?
(Vereist)
make your choice
no
yes
yes, since an injection against itchiness (prednisone)
Have your dog’s eating habits changed?
(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
yes; a few times a day
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
Does your dog seem to get tired quicker than before? (taking age into consideration)
(Vereist)
make your choice
no
yes
Does your dog have other physical problems/complaints besides skin- and/or earproblems?
(Vereist)
make your choice
no
yes
yes my dog has other physical problems
(Vereist)
does your dog take medication for these complaints/problems?
(Vereist)
make your choice
no
yes
What medicines are used?
(Vereist)
Questions regarding infectious diseases
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
Yes, your other pets are:
(Vereist)
Does/do your other pet(s) also have skinproblems and/or itchiness?
(Vereist)
make your choice
no
yes
Do you, or other persons who come in contact with the dog, have skinproblems which started around the same time?
(Vereist)
make your choice
no
yes
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 product(s) do you use?
(Vereist)
Questions regarding your dog’s diet
Did your dog follow a special diet for his/her skinproblems?
(Vereist)
Maak keuze
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 any extras during this diet? (bones, vegetables, fruit, sweets
(Vereist)
Maakt uw keuze
no
yes
We gave extras like:
(Vereist)
How long has your dog been on this diet?
(Vereist)
Did the skinproblems seem to get better?
(Vereist)
Is your dog on a special diet for other than skin related problems?
(Vereist)
Maak uw keuze
no
yes
What kind of other problem?
(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
Medication 3
Name
From and until when given
Effect
Shampoos, ointments etc.
Name
From and until when given
Effect
Shampoos, ointments 2
Name
From and until when given
Effect
Shampoos, ointments 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
