Dermatology Exam Questionnaire

Skin and coat issues are among the most common reasons pets visit the veterinarian. Allergies, infections, parasites, or environmental triggers can all affect your pet’s comfort and health. This dermatology questionnaire helps us better understand your pet’s history and symptoms so we can provide targeted, effective treatment.

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About This Form

By completing this Dermatology Exam Questionnaire, you provide our veterinary team with essential details about your pet’s health, environment, and lifestyle. This information helps us determine possible causes of your pet’s skin or ear condition and guide the best treatment plan.

Client Information

Owner's Name *

First

Last

Phone Number *

Please enter a valid phone number.

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Information

Pet’s Name *

Pet's Date of Birth

What Is Your Pet Here for Today? *

How Is Your Pet’s Appetite? *

How Is Your Pet’s Water Intake? *

Any Changes in Your Pet’s Urination? *

How Is Your Pet’s Energy Level? *

What Brand of Food Do You Feed Your Pet? *

How Much Does Your Pet Get (½ Cup, 1 Can) and How Often? *

Has There Been Any Recent Food Changes or New Treats Offered? *

Does Your Pet Have Any Abnormal Licking or Scratching? *

Does Your Pet Have a History of Ear Infections? *

Does Your Pet Have a History of Itchiness? *

Do You Remember When the Problems Started? *

(as a puppy/kitten, after moving here, around 1–3 years of age)

Medications

Is Your Pet on Any Medications? *

Include Heartworm and Flea Prevention

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Dermatology Exam Questionnaire

About This Form

Client Information

Patient Information

Medications

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