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Mission Veterinary Hospital
7195 Horne Street
Mission, BC V2V 3X9
(604)826-8456
E-mail: missvet@shawbiz.ca

You can assist us to expedite your check in by submitting the appropriate form from the list below.

Thank you for your cooporation in letting us assist you

Form - Dermatology Questionnaire Form

Pet's Name
First Name
Last Name
Appointment Date/Time

How old was the animal when obtained?

where from?
kennel
pet shop
private breeder

Describe your pet's problem

Did the problem start suddenly or gradually?

How has the problem changed in appearance? Has it spread? Worsened?

What previous treatments has your pet received? How effective were they?

What medications is your pet currently receiving? (Please include any supplements as well)

Does your pet excessively; (check all that apply)
itch
scratch
rub
bite
lick
chew
groom
If yes, when?
constantly
sporadically
at night

Where?
face
eyes
ears
muzzle
neck
fore legs
hind legs
paws
back
chest
belly
groin
anus
tail
Is the problem now, or has it ever been seasonal?
Selection
summer
fall
winter
spring
Where do you live?
city
suburban
rural

Has your pet ever been out of Canada?
Is the problem worse when;
indoors
outdoors
equally bad

Has your pet been boarded? If yes, when and where?

Do you have any other pets/animals?
Do they have any problems? If yes, please describe.

Has your pet had any contact with other animals with skin problems? If yes, please describe

Are any people in the household affected with skin problems? If yes, please describe

Does your pet have exposure to (check all that apply);
cats
wool
carpets
tobacco smoke
Where does your pet sleep?

Describe your pets diet: (if possible specify brand and type)
Commercial food

Table foods

Treats/snacks

Supplements

Have there been any changes in the diet? If yes, when? Was the skin affected?

Does your pet go to a groomer?
When was the last visit?

Do you bathe your pet?
What products do you use?

In the last 6 months, have you treated your pet for any of the following?
fleas
mange
intestinal worms
heartworm
What products did you use and when?

Please note if any of the following are abnormal (increased/decreased)
appetite
bowel movements
water consumption
urination
weight
Does your pet do any of the following;
cough
sneeze
runny eyes
vomit
diarrhea
Does your pet have any other health conditions? If yes, please describe.

Does your pet currently receive medication for these problems? If yes please describe.

Is your pet spayed/neutered?
Unspayed female: last heat cycle;


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