Dermatology New Patient History Questionnaire (MVA) - Metropolitan Veterinary Associates

Primary Reason for Visit

Primary reason for your visit today*

Section 1: Household and Medical History

1a. Where did you obtain your pet?

1b. At what age was your pet when obtained?

If no, where did you move from and when?

Please describe (changes in activity or weight):

If yes, please describe:

1j. What food are you feeding now?

If yes, which food and for how long?

If Other species, please specify:

Section 2: DOGS only

If yes, which flea preventative?

If yes, which heartworm preventative?

2d. When was your dog last tested for heartworm disease?

Section 3: CATS only

3a. Indoor/Outdoor? If outdoors, how often?

If yes, which flea preventative?

Section 4: History of skin/ear issues

Other issues (please list)

4b. Describe how the problem first appeared:

4c. Duration of any skin/ear problems (e.g., # days / # weeks / # years)

Age at 1st occurrence (if applicable)

4f. Itchiness level now (1 = occasional scratch, 10 = severe constant)

4g. Where on the body does your pet scratch/lick/bite/rub the most?

If yes, please explain (how it differs):

If applicable: The problem begins in (month) and ends in (month)

If yes, please describe the coincident changes:

Section 5: Previous/Current treatments

List treatments/medications used for skin problems (antibiotics, antifungals, ear meds, steroids/antihistamines, etc.), with dates/duration and effectiveness.

Tx #1 (name/dose/dates/duration)

Tx #2 (name/dose/dates/duration)

Tx #3 (name/dose/dates/duration)

Tx #4 (name/dose/dates/duration)

5b. List ALL current medications (include NSAIDs if used as needed). Note: NSAIDs and steroids should not be given together.

Who may we thank for your referral today? (vet/groomer/friend/etc.)

If yes, insurance provider

Communication Preferences

Treat comments (allergies/preferences)

When discussing treatment, do you prefer a big-picture approach or in-depth detail of all disease processes/diagnostics?

Preference: multiple procedures up front for faster answers vs. step-by-step approach?

Regarding treatment for your pet, will decisions be time- or financially-focused?

Email (if preferred)

Telephone # (if preferred)

Comments to help improve communication overall

Allergy Testing Preparation (Information)

No breakfast (no food after midnight), water is ok
No Apoquel for 2 days
No Antihistamines for 14 days
No Oral Steroids for 21 days
Antibiotics do not matter

We do not want your pet to be uncomfortable; if you prefer to keep current meds, the doctor can adjust and plan testing for another day.