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Patient Information: Case No: Date
Patient Information: Case No: Date
Date:
PATIENT INFORMATION
Case number
Owners Name
Address
Pets Name
Breed
Age
Sex
Colour
Mobile
GENERAL HEALTH INFORMATION
Pet's diet (include the number of times fed per day):
1
2
3
4
5
6
7
8
Pet's lifestyle:
Percent of time indoors
If outdoors:
always outside
stays in a confined area
roams freely
6
7
8
9
10
DERMATOLOGY HISTORY SHEET
Case No:
Date:
Summer
No
Yes
Fall
No
Winter
Yes
Moderate
Mild
feet/legs
arm pits
face
all over
ears
other
Yes
No
No
Maybe
Yes
Never
Occasionally
Frequently
8. Do other pets that have contact with the patient have skin problems?
contact with other animals.
9. Do littermates or the parents of the pet have skin problems?
Unknown
10. Have any people in the house developed skin problems?
Yes
Yes
Yes
No
No
No
No
2
Case No:
Date:
With
With what
13. Which medications have been used to treat the skin problem?
DERMATOLOGICAL EXAMINATION
Case No:
Date:
LABORATORY RESULTS
1. Skin scrapping:
2. Tape impression:
3. Impression smear:
4. FNAC:
5. Skin biopsy:
Case No:
6. Blood workout:
Haemogram
Hb
ESR
PCV
RBC
Reticulocyte count
WBC
Platelet
Blood Parasite
Date:
g/dl
mm/hr
%
m/cmm
%
/cmm
Lakhs/cmm
Differential count
Neutrophils (Mature)
Neutrophils (Banded)
Lymphocytes
Monocytes
Eosinophils
Basophils
Blood picture
7. Serum Biochemistry:
Total protein
Albumin
Globulin
Sodium
Potassium
8. Immuno-histochemistry: