Telephone: 612-624-4831
email: vetderm@umn.edu

Please assist us by completing the requested information.

Please note that fields with an asteris (*) are required fields.




CLIENT INFORMATION
 
 

PATIENT INFORMATION

 


OR (fill in one of the other)
Enter in years & months, i.e., 5 yrs, 3 mos


REASON FOR VISIT & EXPECTATIONS


PART I: HISTORY






  • If no, when was the first occurrence?



If yes, which seasons?


If yes, which seasons?






  • If yes, please include species?




  • If yes, please include species?









  • If yes, what does it hunt?



PART II: MEDICAL HISTORY


  • If yes, please list medications, including dosage & frequency
    (i.e., Prednisone, 5 mg, by mouth, one time per day)


    Response to current medications








  • If yes, which food?

    If yes, what was the duration of the food trial?


    How much improvement was seen?


    Was any chewable or flavored medication (including heartworm) given during the food trial?


  • If yes, was it a:


    If yes, has your pet been on allergy shots?
    How long were allergy shots administered?


    How much improvement was seen:




  • List vaccine(s) and date(s) given



  • If yes, please describe



  • If yes, please describe
PART III: DERMATOLOGICAL SYMPTOMS



  • If yes, describe licking location & frequency?



  • If yes, describe location & frequency?



  • If yes, describe location & frequency?



  • If yes, describe location & frequency?





PART IV: GENERAL SYMPTOMS


  • If yes, please describe:



  • If yes, please describe:



  • If yes, please describe:



  • If yes, please describe:




  • If yes, please describe:



  • If yes, please describe:



  • If yes, please describe:



  • If yes, please describe:




  • If yes, please describe:



  • If yes, please describe:
PART V: OTHER QUESTIONS OR CONCERNS


  • If yes, please specify the type of care provider