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
Phone*
Email*
Patient Information
Animal's Name*
Breed*
Color
Weight (lbs)*
Animals Age:*
Date of Birth*
Date Format: MM slash DD slash YYYY
How long have you owned your pet?
Where did you obtain your pet?
Date of Last Booster Vaccine:
Date Format: MM slash DD slash YYYY
Date of last Rabies Vaccine:
Date Format: MM slash DD slash YYYY
Date the skin problem was first noticed:
Date Format: MM slash DD slash YYYY
Animal's age then:
Gender*
Species:*
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. itching, sores, etc)
Have you seen?*
- Rashes
- Red Bumps
- Hives
- Hair Loss
- Flaking Skin
- Sores
Are there any areas in the animal'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?
If you have a cat, does it go outdoors?
- Yes
- No
Do any people in the home have any rashes, skin lesions, or itching?
- Yes
- No
If so, please describe;
Does your animal have contact with other animals?
Is your animal ever groomed or boarded?
- Yes
- No
If so, please describe;
Does your animal itch?*
- Yes
- No
If yes, when?
- Constantly
- Sporadically
- Nightly
Does your animal?*
- Lick
- Chew
- Rub
If so, please describe;
Does your animal lick his/her feet?*
- Yes
- No
Does your animal shake his/her head?*
- Yes
- No
Does your animal rub his/her face?*
- Yes
- No
Does your animal get ear infections?*
- Yes
- No
What current flea and tick products are you using? (i.e., Frontline, Advantage, Program)*
Has your pet been exposed to fleas?
- Yes
- No
If yes, when?
Is your animal 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 animal been on the medications:*
Is your animal currently on medications? If yes, please list;*
Is your animal allergic to any medications? If so, please list;*
List medications that have helped;*
List medications that have not helped;*
Has your animal been on steroids (Prednisone, Cortisone) at the same time?*
Can you bathe your animal at home*
- Yes
- No
Do you bathe your animal 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 of your animal:*
What is your animal's current diet?*
Has the animal been placed on a strict hypo allergic 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?
Was your animal fasted today?*
- Yes
- No
Is your animal lethargic?*
- Yes
- No
Is your animal drinking normally?*
- Yes
- No
Is your animal eating normally?*
- Yes
- No
What brand and flavor of food are you feeding your pet? i.e., Natural Balance Dry, Salmon and Potato, Hills, Purina
List treats you feed your pet. This includes table/"human foods", rawhides, biscuits, etc
What issue(s) is your pet experiencing that prompted you to request a consultation with Dr. Stewart?
Who referred you to us?
Address:
Phone
What other facts do you think will be helpful?
Payment Policy*
Payment is reqiured at the time services are rendered.
- Agree