Dermatology History Form Use this online form to provide as much information about your pet as you can. Dermatology History Client's Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Patient InformationPet's Name*Breed*ColorWeight (lbs)*Pet's Age:*Date of Birth* MM slash DD slash YYYY Gender*Select oneMaleMale NeuteredFemaleFemale SpayedHow long have you owned your pet?Where did you obtain your pet?Date of last Rabies Vaccine: MM slash DD slash YYYY Date the skin problem was first noticed: MM slash DD slash YYYY Pet's age then:How did you hear about our clinic?Is it a year-round problem?* Yes No Where on the animal did the problem begin?What did it look like then?How has it changed or spread?What is the primary problem? (ie. scratching, sores, etc)Have you seen? Rashes Red Bumps Hives Hair Loss Flaking Skin Sores Are there any areas on the pet's body where the skin problem predominates?* Yes No If yes, where?Do you have any other animals in the home? Yes No If so, describe species and how many?Do any people in the home have any rashes, skin lesions, or itching? Yes No If so, please describe;Does your pet have contact with other animals?Is your animal ever groomed or boarded? Yes No If so, please describe;Does your pet scratch?* Yes No If yes, when? Constantly Sporadically Nightly Does your pet?* Lick itself Chew itself Rub against furniture, the floor, etc. See attached If so, please describe;Does your pet lick his/her feet?* Yes No Does your pet shake his/her head?* Yes No Does your pet rub his/her face?* Yes No Does your pet get ear infections?* Yes No What current flea and tick products are you using? (i.e., Frontline, Simparica, etc)*Is your pet currently taking any medications for his/her skin problem?* Yes No If yes, list names of the drugs and doses if you know them;*How long has your pet been on the medications:*Is your pet currently on any other medications? If yes, please list;*Is your pet allergic to any medications? If so, please list;*List medications that have helped;*List medications tried that have not helped;*Can you bathe your pet at home?* Yes No Do you bathe your pet at home?* Yes No What Shampoo are you using?*Do you clean your pet's ears?* Yes No If so, do you have a cleaner? Yes No If so, describe and list product name if possible:Also, describe the process of how you clean the ears:Do you medicate your pet's ears?* Yes No If so, describe the medications and list the product names, if possible:List any illnesses yout pet already has:*What is your pet's current diet?*Has your pet been placed on a strict hypoallergenic diet study to determine if he/she is allergic to food?* Yes No What was the protein source?If so, describe the product name and the length of time the animal has been on it?Did you give him/her treats or table foods during that time?Is your pet lethargic?* Yes No Is your pet drinking normally?* Yes No Is your pet eating normally?* Yes No What brand and flavor of food are you feeding your pet? e.g., Natural Balance Dry, Salmon and Potato, Hills, PurinaList all treats you feed your pet. (This includes table scraps, rawhides, biscuits, etc)What issue(s) is your pet experiencing that prompted you to request a consultation with Dr. Stewart?Who referred you to Veterinary Dermatology of New England?Address:PhoneWhat other facts do you think will be helpful?Payment Policy*Payment is required at the time services are rendered. Agree ONLINE FORMS Dermatology History Policy Agreement Veterinarian Referral
