Patient Name
Date
Owner Name
Address
Chief Complaint
Age of Pet When Acquired
Age of Pet Now
Where did the problem first appear?
How long has your pet had this problem?
Is your pet itchy?
Is there a time when the problem is less severe, or the itching is less intense?
Is your pet? (check all that apply)
If itching is present...
Grade on a scale of 1 (very mild) to 10 (severe/constant)
Where? (check all that apply)
Is it year round?
Is it seasonal?
If seasonal, which season(s)?
Has there been any ear disease? (current or in the past)
If so, when?
Please list any other health problems your pet may have/is being treated for.
Current Diet
Commercial Food
Commercial Food Name
Table Foods/Treats
Type of Table Foods/Treats
Any known reactions to food/treats/diet in the past?
Any previous special diets for skin disease?
Please list all current medications your pet is taking (please include all steroids, antibiotics, antifungals and ear medications)
Medication 1
Is it helpful?
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Please list all previous medications your pet has taken (please include all steroids, antibiotics, antifungals and ear medications)
Was it helpful?
Please list all other medications (for non-dermatologic related illnesses)
Please list any known drug reactions or allergies (topical or systemic)
Please list all shampoos, lotions, sprays and/or wipes and how often you use them
Flea Control
Which product do you use?
How often do you apply/give it?
Do you give it year-round or seasonally?
Have you ever seen fleas on your pet?
Have you ever seen fleas on other pets?
Heartworm Prevention
How often do you give it?
Percentage of time your pet spends...
Indoors
Outdoors
Does your pet go to doggie day care, dog parks, get groomed or get boarded regularly?
Are there any other pets in the household?
If yes, do any of the other pets have disease or are they itchy?
Do any in-contact humans have skin disease?
