Recheck Intake – Petderm

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Owner and Patient Information

Last Name*

First Name*

Phone Number

Email

Pet Name*

History

Have you noticed any changes in your pet's condition since their last appointment - good or bad?*

Which parts of its body does your pet focus on?

What is your pet's current itch score?

Moderate Itching (Frequent Episodes):
My dog is itching occasionally throughout the day but is not itching while eating playing, sleeping or whie being distracted. Itching ensues at night when observed.

Medications

Current Medications: names, doses and frequency. Length of prescription. Any other details.

Habits and Diet

Fecal Score*

Frequency/number per day?

What is your pet currently eating? Include treats, human food, and / or supplements.*

Additional Information

What are your goals for your upcoming appointment?*

Relevant Images of Skin or Medical History

Files must be smaller than 5mb. If your file is larger than 5mb, please email it directly to referrals@petderm.ca.

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1		Very hard and dry, often expelled as individual pellets so requires much effort to expel from the body and leaves no residue when picked up.
2		Ideal score Firm but not hard, segmented in appearance with little to no residue on the ground when picked up.
3		Log-shaped with little or no visible segmentation, moist on the surface leaving residue on the ground but generally holds form when picked up.
4		Very moist and soggy, log-shaped with no segmentation, leaving residue on the ground and losing form when picking up.
5		Very moist and soggy, log-shaped with no segmentation, leaving residue on the ground and losing form when picking up.
6		Has texture but no defined shape. Presents as piles or spots and leaves residue when picked up.
7		Watery, has no texture and appears as flat puddles.