EXAM Dermatology EXAM Dermatology This form is designed to help our team gather important information about your pet's current status for your upcoming visit to our Fear Free clinic! Your pet's name:* Your name:* Describe your pet's symptoms:*When did your pet start experiencing symptoms?*How many times a day do you see this is happening?* Has your pet's smell changed?* Was your pet previously treated for similar condition? If yes, describe the condition and treatment:* If you are using a shampoo or other topical product, please take a photo and upload below:Max. file size: 300 MB.How often do you bathe your pet?*If you are using an ear cleanser, please take a photo and upload below:Max. file size: 300 MB.How often do you clean your pet's ears?*What kind of food are you feeding your pet? Please upload photos of your pet's food and any treats below: Drop files here or Select files Max. file size: 300 MB. Yes Yes No What table scraps/homemade cooking or treats does your pet get?*How long has your pet been on his/her current diet? When was the last time it was changed or he/she was fed something different?*Have you noticed any changes in your pet's personality or behaviours?* yes no Please rate your pet's itchiness score from 1-10, 1 being not itchy at all, 10 being extremely itchy.*12345678910Please rate your pet's stool quality score from 1-5, 1 being profuse diarrhea, 5 being extremely hard.*12345If stool quality score is 3 or above, please bring a stool sample with you to your appointment!In your opinion, is your pet drinking more frequently?* yes no unsure In your opinion, is your pet urinating more frequently?* yes no unsure Have there been any recent accidents in the house?* yes no Has your pet's energy levels changed?* more energy less energy no change Has your pet experienced recent vomiting?* yes no Does your pet attend grooming/boarding/daycare/dog park facilities?* yes no Does your pet hunt?* yes no Does your pet roam freely outdoors?* yes no Does your pet eat feces/drinks outdoor water from wildlife/other pets/its own?* yes no Was your pet living in or traveling with you to heartworm/tick endemic area in the last 12 months? (States, south west/Northern Ontario)?* yes no Is your pet on heartworm prevention?* yes no Is your pet on flea/tick prevention currently?* yes no Please upload photos of your pet's flea/tick and/or heartworm prevention products below: Drop files here or Select files Max. file size: 300 MB. Do you have any doses left over from last year?* yes no Have you seen any fleas/ticks on your pet in the last year?* yes no Would you like us to get your pet started on Lyme vaccine?* yes no unsure, I'd like more information How did your pet do after last year's vaccines? Was there any reaction to the vaccines?* yes no Is your pet currently microchipped? Would you in interested in a Tchip for your pet?* My pet is microchipped My pet is not microchipped Yes, please Tchip my pet! Has your pet bitten any person in the last 10 days which broke the skin?* Yes No Please list any questions/problems/concerns for Dr. Jinni that you would like addressed:Does anyone in your household have a peanut allergy?* yes no Δ