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    DERMATOLOGY HISTORY AND EXAMINATION FORM PRESENTING COMPLAINT PRESENTATION Age of onset INITIAL clinical signs Duration of disease Seasonal variation Progression PRIOR INVESTIGATION PRIOR THERAPY NOTES LESION MAP VENTRAL GENERAL EXAMATION Temp / pulse / respiratory rate Superficial LN Alimentary Cardiovascular Genital Musculoskeletal Nervous respiratory Urinary DORSAL D

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    [Dermatology History and Examination Form]

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    DERMATOLOGY HISTORY AND EXAMINATION FORM PRESENTING COMPLAINT PRESENTATION Age of onset INITIAL clinical signs Duration of disease Seasonal variation Progression PRIOR INVESTIGATION PRIOR THERAPY NOTES LESION MAP VENTRAL GENERAL EXAMATION Temp / pulse / respiratory rate Superficial LN Alimentary Cardiovascular Genital Musculoskeletal Nervous respiratory Urinary DORSAL D

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    Attribution Non-Commercial (BY-NC)
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    1K views4 pages

    Dermatology History and Examination Form

    Uploaded by

    Ђорђе
    DERMATOLOGY HISTORY AND EXAMINATION FORM PRESENTING COMPLAINT PRESENTATION Age of onset INITIAL clinical signs Duration of disease Seasonal variation Progression PRIOR INVESTIGATION PRIOR THERAPY NOTES LESION MAP VENTRAL GENERAL EXAMATION Temp / pulse / respiratory rate Superficial LN Alimentary Cardiovascular Genital Musculoskeletal Nervous respiratory Urinary DORSAL D

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    of 4

    The Queen Mother Hospital for Animals

    Clinician_____________________________________
    Date ______________________________________
    Case label here
    Referring Vet ________________________________
    Telephone (H) ______________________________
    Telephone (W) ______________________________
    Insured YES / NO Company __________________

    DERMATOLOGY HISTORY AND EXAMINATION FORM

    PRESENTING COMPLAINT

    GENERAL HISTORY

    Age when acquired Time owned

    Exercise

    Respiratory

    Gastrointestinal

    Appetite Thirst ml/day

    Urine/faeces

    Sexual

    Discharges

    Previous illness or injury

    SOURCE

    RELATED ANIMALS/IN CONTACTS

    Littermates/parents No data or unknown ❏

    Animal contacts Casual contacts only ❏

    Human contacts

    ENVIRONMENT

    Indoor Full run of house ❏


    Sleeping area

    Outdoor Free access/egress ❏

    RM 85469
    DIET Never or rarely given

    MANAGEMENT
    Parasites seen No parasites seen ❏
    Parasite control Environmental control

    Grooming
    Bathing

    Other therapy

    INITIAL PRESENTATION
    Age of onset Duration of disease
    Initial clinical signs

    Seasonal variation Non-Seasonal ❏


    Progression

    PRIOR INVESTIGATION

    PRIOR THERAPY

    NOTES
    LESION MAP

    VENTRAL DORSAL

    GENERAL EXAMINATION
    Temp/pulse/respiratory rate
    Superficial LN
    Alimentary
    Cardiovascular
    Genital
    Musculoskeletal
    Nervous
    Respiratory
    Urinary

    DERMATOLIGICAL EXAMINATION
    DIFFERENTIAL DIAGNOSES

    INVESTIGATION

    PRESENTING COMPLAINT
    Provisional/Confirmed

    TREATMENT

    COMMENTS AND ADVICE GIVEN

    NEXT APPOINTMENT

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