Second Opinion Dermatology Service Dermatology/Allergy Clinic Veterinary Medical Teaching Hospital University of Wisconsin-Madison SECOND OPINION is an electronic service for referring veterinarians in the practice area of the School of Veterinary Medicine, University of Wisconsin-Madison. Instructions: 1. Complete the fillable PDF (5 pages). 2. Upload the completed form and any attachments: photos, laboratory results, medical records, typed summary. 3. Email this form to dermsecondopinion@vetmed.wisc.edu 4. Requests are completed in the order they are received. Please allow 3-5 business days for a response. 5. Please note that our responses are informational only; we do not assume liability or responsibility for patient outcome. The charge for this service is $50.00 and will be billed to your account monthly. Veterinarian Contact Information Referring Veterinarian Clinic Name and Address EMAIL Owner s Name Pet s Name Species DOB Breed Gender: M F N Weight (kg) OWNER S CHIEF COMPLAINT: 1. Age of onset of clinical signs 2. Duration of current problem 3. Was the onset? Gradual Sudden Other
4. Describe initial appearance and how it has changed. 5. Problem is Continual, even with treatment Continual, but better with treatment Intermittent (describe) 6. Is the problem seasonal? Yes No If Yes, when? 7. What was the severity of the itch over the last year? None Mild Moderate Severe 8. What was the severity of the itch over the last MONTH? None Mild Moderate Severe 9. Is there a history of fleas? Yes No Don t Know 10. What flea preventative is being used? 11. Are other animals in the home? Yes No List below 12. Do these animals have concurrent skin disease? 13. Are other animals receiving flea and tick preventative? Yes No Don t Know 14. What diet is routinely fed?
15. Have any special diets been tried as treatment? List type, duration, was it exclusive? 16. Pet lives Indoors primarily Outdoors primarily Other 17. What other medical problems does the pet have? 18. List CURRENT(receiving now) MEDICATION AND DOSAGES 19. What is your working diagnosis? 20. What specific question (s) can we answer?
CLINICAL SIGNS OBSERVED BY OWNER OR VETERINARIAN (Check one box for each symptom) SIGN Never None Rarely Slight Occasionally Moderate Often Severe Please Explain: Location on Body or Other Comments Pruritus Hair loss or poor regrowth of hair Erythema Papular or pustular eruption Scaling/flaking/seborrhea Increased odor of skin or coat Crusting or scabbing patches on skin Erosions or ulcerations Purulent skin lesions/draining areas Eyes - redness, irritation, itching, discharge Change in color or texture of hair Hyperpigmentation Loss of pigmentation Ear infections Fleas seen on pet Diarrhea or loose stools Vomiting Sneezing or wheezing Changes in pet s usual personality Changes in pet s usual activity level Weight loss or weight gain Changes in pet s appetite Changes in amount of water consumed Changes in urinary habits DISTRIBUTION OF PRURITUS (Check one box for each body area) BODY AREA Feet / paws Legs / arms Abdomen (belly) / genital area Armpits / chest / sides of body Face / eyes Ears / ear flaps Along the back or rump The tail itself Anal area Not Mildly Moderately Severely Comments Comments:
SUMMARY OF DIAGNOSTIC TESTING PERFORMED TO DATE (attach results if necessary): TEST DATE PERFORMED RESULT Skin Scrapings Impression Smears of Skin Fungal Culture Bacterial Culture Skin Biopsy CBC Serum Chemistries Urinalysis Allergy Test (specify lab) Please list all prior treatments and response. Include all corticosteroids, antibiotics, antipruritic drugs, hormonal treatments, topical treatments, etc. Please indicate if drugs were used alone or in combination. DRUG or COMBINATION OF DRUGS DOSAGE(s) LENGTH OF TREATMENT RESPONSE or COMMENTS EMAIL this request and any supporting documentation to: DermSecondOpinion@vetmed.wisc.edu. You will receive a reply within 3-5 business days.