Pets name
Photo The SAVIN Pet Hospital
Where ever you’re
Reg Date
Reg No
Owner’s name: Species Breed Age Sex Body weight
Kg
Address:
Phone Number:
Vaccination Brand Date Remarks
Deworming Brand Date Remarks
Bathing Soap / shampoo Date Remarks
Medical History
Surgical History
O / G History
• Primary complaints
• Areas affected
• Does it recur?
• Non dermatological complaints
Hair loss / discolorations / itching / smelling / self mutilation / alopecia/ dry scales / other…………….
Dorsal Ventral Facial Tail Paw
Other ……………………………..
Yes No Frequency ……Day….Month………….
Obesity / excess thirst / limb swelling / Yawning / recent estrus / other…………
• Duration of suffering
• Duration treated , Vets name
• Treatments details
Dr
Remarks :
• Is it breed predisposed condition
• Congenital or hereditary problems
Or developmental problem?
• Is it intact or spayed or Cryptorchid Yes No
No Yes Describe …………………..
Int Spy Cryp
• Itching and its severity None Moderate Severe
Lick Rub Scratch Chew
• Food allergy
• Drug Allergy Food Beef Pork Fish other
Sulpha penicillin Ceftr Bcomplex Other ………………………………….
• Evidence of occurring in seasons Yes No
• Presence of fleas or ticks Yes No
• Response to old treatments To steroids
To Antibiotics
• Frequency of bath Frequent 7 15 21 30 30+ none
• Environment animal stays Indoor Outdoor
• Does it come across other animal Household stray none
• Household disinfectants used Black phenyl
• Any use of OTC human products recently
• Any Further Details:
Diagnostic Test results Date
TC S LIPD T3 Antibogram Remarks
N RBS T4
M TSH TP
L FECAL PARASITE Microscopy
E TYPE
B URINE
CREA
BUN SMEAR
OTHER
Tentative Diagnosis Prognosis Confirmative Diagnosis
Date Observation Treatments & Advice
Date Observation Treatments & Advice
Date Observation Treatments & Advice
Date Observation Treatments & Advice
Date Observation Treatments & Advice
Date Observation Treatments & Advice
Date Observation Treatments & Advice
Date Observation Treatments & Advice
Final outcome ……………………………………………………………………………….
