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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?) ___________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________