P: 239-263-0480
F: 239-263-0488

10130 Market Street • Naples, FL 34112

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Board-Certified Diplomate of the American College of Veterinary Dermatology
Board certified specialists in Dermatology located in Naples FL
Naples FL Board certified specialists in Dermatology

Dermatology Questionnaire


You can also download our PDF version and fax it / mail it. Download dermatology questionnaire here

Your First & Last Name:

Name of Pet:

Date of Birth (approx):

Date Acquired (approx):

Spayed/Neutered:
Date:

Primary Complaint(s):

Date Problem Started (approx):

Condition Currently Seasonal?

Was Condition Initially Seasonal?

Is There a Time When Disease is Less Severe? (If so, explain)

Occasions Symptoms are Worse?

First indications of problem:
(Select all that apply)
Hair Loss Rash Pimples Redness
Normal Skin, But Itchy

Where did the problem start?
(Select all that apply)
Nose Ears Eyes Neck Back
Rump Tail Front Legs Front Paws
Back Legs Back Paws Abdomen
Groin Chest

Does pet scratch, rub, chew, lick, or bite any of these areas?
(Select all that apply)

Nose Ears Eyes Muzzle Neck
Back Rump Tail
Inner Legs and Thighs Armpits
Front Legs Front Paws Back Legs
Back Paws Abdomen Groin Chest
Chin

Has the Problem Spread? (If so, explain)

How Itchy is Your Pet? (10 being most severe)

Does your pet exhibit any of the following?

(If you select a symptom, please list frequency and description)


Household (If Any Item Selected Please Explain)

Do You Have Other Pets (List type)?
Explanation:

Are Other Pets In Home Affected by Condition?
Explanation:

% of Time Pet is Indoors (0-100):
Explanation:

Do Any People In Your Home Have Skin Problems?

Explanation:


Flea Control / Heartworm Prevention / Bathing

Use Flea Control on Pet?
(explain type and frequency)

Use Environmental Flea Control in Home or Yard?

Describe Foods and Treats:

How Long on This Diet?

Vitamins or Supplements?

Bowel Movements per Day?

Any Medications or Injections Used For Skin Condition?

How Often Do You Bathe Your Pet?

Shampoos or Bathing Products:

Heartworm Prevention? (List type, frequency)

Any Other Pet Medications (List type, frequency)?

Have Any Medications Helped the Condition?

How Many Times Has Pet Been Treated for Condition?

Has Pet Been Treated for Stomach or Intestinal Problems?


Specialty Services


Animal Specialty Hospital of Florida © 2016
10130 Market Street | Naples, FL 34112
P: 239-263-0480
F: 239-263-0488

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