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About Us
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Veterinary Topics

Online Pharmacy

Phone
405-265-6262

Fax

405-655-5669

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Chronic Skin/Allergies Questionnaire

Chronic Skin/Allergies Questionnaire

Name: Cornerstone Veterinary Hospital
Address: 10500 S. SOONER RD, Oklahoma City, OK, 73165, US
Telephone: 405-265-6262

To better understand and treat your pet’s condition, please complete the questionnaire below regarding
their complete medical history. Please be thorough as this will allow us to focus on your pet’s physical
exam and discussing treatment options. Please bring your pet’s medications, topicals (sprays,
shampoos, etc.), and diet/treat ingredients to your appointment.

Do you currently have an appointment scheduled? If so, when?

Client Name:

First Name*

Last Name*

Email *

Name of previous veterinary clinic where we may acquire records:

Species

Dog Cat

Breed

Sex

In-tact Male Neutered Male In-tact Female Neutered Male

Age of Pet

General History

At what age was your pet acquired?

How was your pet acquired (breeder, shelter, etc.)?

Any current diagnosed medical conditions?

Does your pet have any coughing, sneezing, vomiting, or diarrhea? If so, for how long?

Has your pet ever been aggressive to humans or other animals at home or at the vet? If so, please explain.

When was your pet last vaccinated and against what (Rabies, Distemper, Leptospirosis)?

Describe your pet’s lifestyle/use (hunting, agility, etc), and what % of time indoor/outdoor?

Describe outdoor environment: wood/trees, lawn, fields, etc?

Describe your indoor environment: carpet, wood, tile, basement?

Does your pet swim? If so, where (pond, lake, pool, river)?

Is your pet exposed to wildlife (deer, rabbit, squirrel, fox, etc.) in their yard? If so, what?

Travel history outside of Oklahoma?

What other pets are in your house?

Dermatologic History

Describe your pet’s main dermatologic problems (skin, ears, paws, itching, hair loss, etc.).

What is your main concern for the appointment?

When did the problem start?

First indication of problem?

Hairloss Flaky skin Rash Scabs Scratch normal skin Scratch abnormal skin Pimples Sores Redness Dark skin Blackheads / comedones Masses

Other (please describe)

Where on the body did the problem(s) begin?

Nose Ears Eyes Chest Rump Sides Abdomen Neck Back Groin Claws Front legs Front paws Pads Tail Back legs Back paws

If your pet is itchy, try to enumerate the severity in the following 0-10 scale

9-10: Extremely severe, almost continuous, itching doesn't stop whatever is happening (needs to be physically restrained from itching), wakes up itching during the night. 7-8: Severe itching, prolonged episodes, itching might occur at night (if observed), and also when eating / playing / exercising, unable to distract from itching. 5-6: Moderate itching, regular episodes, itching might occur at night (if observed), but not when eating / playing / exercising, difficulty to distract from itching. 3-4: Mild itching, periodic episodes, won't itch while sleeping / eating / playing / exercising, easily distracted from itching. 1-2: Very mild itching, only occasional episodes, pet is slightly itcher than what is considered acceptable 0: I don't think itching is a problem

Is the problem(s) present all year-round or is it seasonal?

All year-round Seasonal

If seasonal, when is it present?

Spring Fall Summer Winter

Has the problem / dermatitis spread? If so please describe

Does your pet ever have any hay-fever type symptoms

Runny / itchy eyes Sneezing / wheezing No, my pet doesn't exhibit these symptoms

Do you have any dermatologic history about your pet's parents or littermates?

Are any other pets or humans in the household having skin problems or itching?

Parasite Control / Prevention

Has your pet ever had fleas or ticks? If so, when was the last time they were seen?

What flea / tick preventatives do you use? How often? Year-round?

Are all other pets (cats and dogs) on flea prevention as well? If so please elaborate

What heartworm/internal parasite prevention is your pet taking? How often? Year round?

Has your pet ever been heartworm positive or diagnosed with a tick-borne disease? If so, please describe.

For cats, has your cat been FeLV/FIV test? What were the results? (Please write NA if your pet is not a cat)

Diet / Medications / Therapeutics

What exact pet food, treats, or human food do you feed your pet now?

Have you ever fed a strict prescription diet or fed a home-cooked diet with a novel protein guided by your vet to rule out a food allergy? If so, explain.

How often does your pet get bathed/groomed?

What products are used when your pet is bathed/groomed?

Does bathing/grooming help, make worse, or no change?

Have you tried any of the following:

Antihistamines (Benadryl, chlorpheniramine, Zyrtec, etc) Antibiotics (Clavamox, cephalexin, Baytril, etc.) Steroids (prednisone, dexamethasone, etc) Nonsteroidal anti-inflammatories (Rimadyl, Metacam, Deramaxx, etc) Antiyeast meds (ketaconazole, fluconazole, terbinafine, etc) Allergy shots Cytopoint Injection Atopica (cyclosporine) Apoquel Topical ointments, sprays wipes Ear cleaners, or medicated ear ointments / drops Medicated shampoos or conditioners Omega fatty acids or other supplements / vitamins My pet has not tried any of these types of medications / products

If you have tried any of the above medication / product types, please list NAME, DOSE, INTERVAL, and please specify if they were helpful. (If your pet has not tried any of the above, please write NA)

Current Medications

Please list all current medication and exact dose/frequency:

Photos

If you have any photos of your pet dermatological condition(s), please attach them below. (.jpg, .pdf files preferred)

Upload Your File

Drag Files or Click to Browse

Overall Goals

Briefly describe your hopes, goals, and concerns that you would like to address during your appointment. This is truly important to us

Thank you. Your submission has been sent.

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Cornerstone Veterinary Hospital

Address

10500 S. SOONER RD,
Oklahoma City, OK 73165

Phone

405-265-6262

Monday

7:30 AM

6:00 PM

Tuesday

7:30 AM

6:00 PM

Wednesday

7:30 AM

6:00 PM

Thursday

7:30 AM - 1:00 PM

2:00 PM - 6:00 PM

*Closed 1PM-2PM for Training*

Friday

7:30 AM

6:00 PM

Saturday

Closed

Sunday

Closed

Contact Us

We look forward to hearing from you

Name*

Email *

Phone *

Comments

Thank you. Your submission has been sent.

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10500 S. SOONER RD
Oklahoma City, OK 73165, US

Phone: (405) 265-6262
Text: (405) 267-8278

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