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Clio Animal Hospital
SMALL ANIMAL & EXOTIC PRACTICE
3474 W. Vienna Rd. Clio, MI 48420  Phone: (810) 687-1972  Fax: (810) 687-2324
www.clioanimalhospital.com
Kendra Reynolds, D.V.M
Skin Evaluation Form
Patient: ________________________ Owner: _________________________ Date: ________________________
Yes
No
?
1. Does the skin condition seem better or worse during any particular season?
If so, which one? ____________________________
2. Do other pets in your household have skin problems?
3. Do any relatives of your pet have skin problems?
4. Do any people in your household have skin problems?
5. Do you use any flea control products? If so which ones have you tried? __________
___________________________________________________________________
6. Do you bathe your pet? If so how often and with what? _______________________
____________________________________________________________________
7. Is there any condition or environment that makes the skin problem noticeably worse?
(i.e., being outside, walking on grass, the day you vacuum, etc.…) ______________
____________________________________________________________________
8. Has your pet experienced vomiting or disagreement with certain foods?
If so, which one(s)? ___________________________________________________
9. Have you tried changing your dog’s diet? If so list what it has ever been changed to.
___________________________________________________________________
10. Has your pet ever seemed to be ill from his skin disease (depressed, fever, not eating,
etc.?)
11. Does your dog eat dry food? If so, what brand and how long have they been on it?
____________________________________________________________________
12. Does your dog eat canned food? If so, what brand and how long have they been on it?
____________________________________________________________________
13. Does your dog get treats? If so, what kind and how often? _____________________
14. Does your dog get people/table food? If so, what kinds of food and how often?
____________________________________________________________________
15. How many times a day does your pet have a bowel movement? _________________
The consistency of each stool is: CIRCLE ONE
Firm and formed
Soft and formed
Loose Diarrhea
Severity Evaluation: On a scale of 0 to 10 rank the severity of your pet’s symptoms.
No Symptoms
0
1
Severe
2
3
4
5
6
7
8
9
10
Please check any of the following that are now present relating to your pet’s skin:
Scratching
Greasy skin or coat
Biting
Scaly skin (dandruff)
Licking
Crusty skin
Rubbing Face on floor/furniture
Redness
Change in thirst
Pimples
Shaking head
“Bumps” on skin
Dry skin or coat
Drags “Butt” on floor
Oozing sores
Body odor
Hair loss
Darkening of skin
Lightening of skin
Thickening of skin
Fleas
Please circle your dog’s problem area(s)
1. How long has your pet had a skin problem?
Years________
Months________
Days________
2. Age of pet when obtained:
Years________
Months________
Days________
3. Age when skin problem started:
Years________
Months________
Days________
4. Where on the body did the problem start? ___________________________________________________________
5. What did it look like initially? ____________________________________________________________________
6. If your pet is scratching, did you notice the itching or the skin lesions first?
Itching
Skin Lesions
7. How has it spread or changed? ____________________________________________________________________
8. On the list of medications below, check which types of medication your pet has been given, and, if so, how much
relief they produced:
Treatment or medication
Treatment or medication
Cortisone pills or shots (steroids, Temaril, prednisone, Vetalog, anti-itch pills)
Antibiotics alone (with no other medication given at the same time)
Antihistamine (Benadryl, Zyrtec, etc.)
Antifungal medications (ketoconazole, etc.)
Cyclosporine (Atopica)
Apoquel
Allergy shots or drops
Was it ever given?
If given, how much did it help?
Yes
Did not help
No
Not Sure
Helped some
Helped a lot
9. Any other thoughts you have relating to the skin disease (e.g., what do you think may be the cause of the skin
problems?) ___________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________