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Contact information: |
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* First Name: | |
* Last Name: | |
* Home Phone: | |
Cell phone: | |
* E-mail: | |
Address: | |
City, Zip Code: | |
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Pet information: |
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Pet's Name: | |
Type of Pet: |
Dog
Cat
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Date of Birth: | |
Gender: | Male Female |
Spayed/Neutered: | Yes No |
Breed: | |
Color: | |
Weight: | |
Date when you acquired pet: | |
Where was your pet obtained: |
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Ears Problems: |
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Any ears problems: |
Yes
No
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Which ear affected: |
Right
Left
Both
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Problem Location:
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Any changes in ear skin color: |
Yes
No
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Symptoms: |
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If ear itching occurs seasonally: |
Yes
No
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Ear discharges: |
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Symptoms: |
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Current Skin Problem(s): |
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If itching occurs seasonally: |
Yes
No
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Itching Degree: |
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Approximate Date when problem FIRST started: |
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Are symptoms getting worse: |
Yes
No
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When did symptoms start to get worse: |
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Where on your pet's body did the problem FIRST begin, check all that apply
or click on pet's body picture for selection:
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What did the problem look like initially: |
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Has problem spread: |
Yes
No
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When/Season/Where did problem spread: |
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Have the ears been involved (infected, waxy,itchy): |
Yes
No
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General Health: |
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Any changes in weight: |
Yes
No
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If YES please select: |
Loss
Gain
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Any decrease in activity levels: |
Yes
No
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Any increase in drinking: |
Yes
No
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Any increase in urinating: |
Yes
No
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Any increase in appetite: |
Yes
No
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Any other medical conditions: |
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Contagion: |
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Any other pets in the household: |
Yes
No
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If YES please list: |
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Do they have any skin problems: |
Yes
No
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If YES please describe: |
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Do any people in the household have skin problems: |
Yes
No
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If YES please describe: |
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Does your dog go to doggy daycare, groomers, dog parks etc: |
Yes
No
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If YES please describe how often: |
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Previous Diagnostic Tests: |
Please write relevant result briefly
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Skin Scraping: |
Yes
No
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Blood CBC, Biochemistry: |
Yes
No
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Cytology: |
Yes
No
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Thyroid Evaluation: |
Yes
No
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Bacteria Culture: |
Yes
No
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Cushing Evaluation: |
Yes
No
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Fungal Culture: |
Yes
No
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Biopsy: |
Yes
No
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Wood Lampe: |
Yes
No
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Serum Allergy test: |
Yes
No
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Elimination Diet: |
Yes
No
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Drug History: |
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Food History: |
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List pet foods, treats (cookies, biscuits, chews, snacks etc) and human food: |
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Message: |
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If you want to send a picture of your pet please use email: mobilevetcare@gmail.com
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