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Thistle
Dermatology Referrals |
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Client
Questionnaire |
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Your name: |
Tel No: |
home |
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Your Address: |
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Work |
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mobile |
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Your
Veterinary Surgeon’s Name: Address: Telephone No: |
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Your pet’s Name: |
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Sex:
M/F
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Age
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Breed |
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Neutered Yes /
No |
When |
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Has your pet been
vaccinated? |
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Is your pet insured? |
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Are there any other animals in the
household? Please specify. |
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Do any people in the house have a
skin condition? |
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How much time does your pet spend
in the house? (circle)
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100% |
75% |
50% |
25% |
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Where does your pet sleep? |
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Where does your pet go for
exercise? |
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Does your pet cope with exercise
as well as he/she used to? |
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What do you feed your pet? |
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What does your pet
drink?
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How much? |
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What is the main skin
complaint? (please circle) |
itching loss of
hair |
dandruff |
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rash |
oily coat |
odour |
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When did you first notice the
problem? |
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Where did the skin condition first
appear? (circle) |
Face belly/groin |
ears legs |
Neck feet |
back trunk |
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Has it got worse since then? |
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Does it have a seasonal pattern?
(circle) |
spring |
summer |
autumn |
winter |
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Is your pet receiving any
medication/shampoos other than those from your Veterinary Surgeon? |
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Is there anything else which you
think may be important? |
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home letter directions |
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