Case No:

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

Other medical problems (those not related to the skin problem):

Pet's lifestyle:
Percent of time indoors
If outdoors:
always outside
stays in a confined area
roams freely

percent of time outdoors

Has a kennel/dog house
walked in public areas
other

Vegetation around home:

1
2
3
4
5

6
7
8
9
10
DERMATOLOGY HISTORY SHEET

1.Briefly state the problem:

Case No:

Date:

2.When the problem was first noted (Month & Year)?

3.Is the problem year round?
Yes, it has always been year round.
Yes, but it used to be seasonal (only part of the year).
No.
Unknown.
4.Are problems more severe during particular season(s)?
Spring

Summer

5.Is there scratching, chewing, licking or rubbing?

Severe

No

Yes
Fall

No

Winter

Yes

Moderate

Mild

Where does your pet itch, chew, lick, or rub?

lower back
belly

feet/legs
arm pits

face
all over

ears
other

6.Where on the body did the problem begin?

7.Are fleas currently present on any of your pets?

Yes

Do you give any medications to prevent fleas?

How often are ticks seen on your pet?

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:

11. How often do you shampoo your pet?

what?
12. How often do you clean your pet's ears?
cleanser?

With

With what

13. Which medications have been used to treat the skin problem?
DERMATOLOGICAL EXAMINATION

Symmetry:________ Yes ________ No

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: