Dermatology Form

Hickory Veterinary and Specialty Hospital


2303 Hickory Road
Plymouth Meeting, PA 19462
610-828-3054
Fax: 610-828-8465
E-Mail: [email protected]
Web Site: www.hickoryvet.com

New Dermatology Patient History Questionnaire:


Kevin Byrne, DVM, MS, DACVD

Has your pet had any adverse reactions to medications or drug allergies?
1. What are your pet’s problems currently? (check all that apply)
Have there been similar symptoms in the past?
3. Is there currently a relationship between your pet’s problem(s) and the season of the year?
If yes, please check the season(s) your pet is affected:
In the past was there a relationship between your pet’s problem(s) and the season of the year?
4. On a scale of 1-10 with 1= occasional licking, chewing, scratching and 10= severe, constant licking, chewing, scratching that keeps you up all night, how would you rate the level of itch currently?
5. Have any treatments or medications helped your pet, even if only temporarily?
6. Do you have any other pets?
Do your other pets have skin problems?
9. Has any person in your household had skin problems since your pet started havig skin problems?
13. Has your pet ever been on a food elimination diet with a prescription diet?
Were treats, table foods, chewable medications, bones, flavored supplements given while on the diet?
15. Does your pet have any other medical or surgical problems unrelated to the skin disorder?
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