Animal Medical Services P.C.  
             "Our family includes you and your pet."

Dermatology Evaluation Form (please copy all pages, fill out, and bring with you to the office.)

Date ________________ Pet owner name______________________

Name of Pet_________________  Age ________ Breed___________________

Body weight____________________

Physical Evaluation:
    Please check any of these that describe your dog and circle problem areas on the drawing.

____ hair loss                  ____ foul odor          ____ inflammaton or redness

____ itching/scratching   ____  otitis (ear infections)

____ licking/chewing                 ____ skin lesions (sores)

____ changes in the skin (reddish brown stains, discolorations,
      and/or areas that are thick and leathery.    

Severity Evaluation.
   Where 0=no symptoms and 10=severe symptoms, rate the following on a 
scale of 0-10.
____ severity of overall condiiton   _____ severity of skin lesions

____ severity of licking/chewing/scratching 

Onset and Seasonality Evaluation.
1. Is this the first time your pet has experienced these symptoms? ___yes ___no
     If no---
    a. At what age did the symptoms first occur? 
           ___<1 yr.  ___ 1-3 yrs    ___ 4-7 yrs  ___ 7+ yrs.
   
     b. Has it occured around the same time of year each time? ___ yes  ___no

     c. When is the approximate time of year that it occurs? ____________________

2. How long have the current symptoms been going on? _____________________

3. Did the itch start gradually and over time get worse? ___ yes   ___ no

4. Did the itch come on suddenly without warning?  ___ yes   ___ no

5. Was there a "rash" first or did the itching occur first or at the same time?
          ___ rash first         ___ itch first        ___ both at same time

Parasite control
1. Is your pet on flea/heartworm preventive?
        ___ yes    ( product(s)_____________________________)
        ___ no 
2. What months do you administer the flea/heartworm preventive?
    flea _______________ through __________________
    heartworm ______________thorugh ________________     

3. When was the last dose of the these medicaitons?
     flea __________________
     heartworm ____________________

Lifestyle Evaluation.
1. This pet lives  inside _____   outside _____  both _____
      If outside, please describe the environment. _______________________
____________________________________________________________
____________________________________________________________
2. Are there other pets in your household?  ___ yes   ___no
   If yes, do they have similar symptoms?       ___ yes   ___ no
   If these pets are cats,  do they go outside?      ___ yes ____ no
3. Do you board your pet(s), take him or her to obedience classes, training, 
  or groomers?   ____ yes   ___ no
    If yes, when was the last time you took your pet? ___________________
4. Have you taken your pet on a trip or to another location? ___ yes   ___ no
    If yes, when was the last trip and where was the destination?  
    _________________________________________________________
5. Have you recently moved?  ___ yes   ___ no
6. Have you been to a new dog partk or walking trail? ___ yes   ___ no  
7. Have you recently used any new shampoo or topical skin treatments recently?
                              ___ yes  ___ no
8. Are any humans in the household exhibiting any skin problems? 
                              ___ yes   ___ no
Dietary Evaluation.
1. My pet eats ___________________________________________________
______________________________________________________________.
2. Do you feed the same food all the time or provide a variety"
           ____ always the same   ___ variety
3. Have you changed the diet recently?         ___ yes   ___ no
4. Do you give your pet packaged treats?   ___ yes   ___ no
5. Do you feed your pet "human" food?  ___ yes   ___ no

Relationship/Behavioral Evaluation.
  Indicate if and how your pet's symptoms have affected his/her behavior and relationship with you.

1.Sleeps through the night: 
            ___ always   ___usually ___ occasionally ___ never.
2. Activity level: 
            ___ inactive  ___much less active  ___ somewhat    __ unchanged
                                                                                 less active
3. Social behavior:
        ___ unsocial  ___a lot less   ___ somewhat    ___ unchanged
                                      social                   less social
4. Relationship changes:
        ___ fewer walks   ___ no longer sleeps     ____ interacts less
                                           in same bed/room            with family
Prior Treatments
1. Has your pet been treated for itching before?  ___   yes   ___   no
2. Indicate previous treatments administered to your pet. (check all
      that apply).
   ___ steroids   ___ shampoos   ___ sprays   ___ ointments

   ___ antibiotics   ___ hypoallergenic foods/diets    ___ essential fatty acids

   ___ antihistamines   ___ immunotherapy.

   ____ other (please specify) _________________________________________

 ________________________________________________________________
(use back of page for additonal notes.)

Again, fill this form out as completely as possible and bring to the office with you for your appointment or fax to us at 423-2645. This history will be reviewed prior to the physical examination. Dr. Butler may elect to collect samples for laboratory testing. These may include 
1. Ear swab- to identify bacteria, yeast, or ear mites
2. Skin scrapings/hair pluck analysis- to detect mange mites
3. Impression smear/tape preparation to identify other skin parasites, bacteria, and yeast.