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 InformationAnimal's Name*Breed*ColorWeight (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*Select oneMaleMale NeuteredFemaleFemale SpaySpecies:*Select oneCanineFelineHow did you hear about our clinic?Is it a year-round problem?*YesNoWhere 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?*YesNoIf yes, where?Do you have any other animals in the home?YesNoIf so, describe species and how many?If you have a cat, does it go outdoors?YesNoDo any people in the home have any rashes, skin lesions, or itching?YesNoIf so, please describe;Does your animal have contact with other animals?Is your animal ever groomed or boarded?YesNoIf so, please describe;Does your animal itch?*YesNoIf yes, when? Constantly Sporadically Nightly Does your animal?* Lick Chew Rub If so, please describe;Does your animal lick his/her feet?*YesNoDoes your animal shake his/her head?*YesNoDoes your animal rub his/her face?*YesNoDoes your animal get ear infections?*YesNoWhat current flea and tick products are you using? (i.e., Frontline, Advantage, Program)*Has your pet been exposed to fleas?YesNoIf yes, when?Is your animal currently taking any medications for his/her skin problem?*YesNoIf 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*YesNoDo you bathe your animal at home?*YesNoWhat Shampoo are you using?*Do you clean your pet's ears?*YesNoIf so, do you have a cleaner?YesNoIf 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?YesNoIf 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?*YesNoWhat 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?*YesNoIs your animal lethargic?*YesNoIs your animal drinking normally?*YesNoIs your animal eating normally?*YesNoWhat brand and flavor of food are you feeding your pet? i.e., Natural Balance Dry, Salmon and Potato, Hills, PurinaList treats you feed your pet. This includes table/"human foods", rawhides, biscuits, etcWhat issue(s) is your pet experiencing that prompted you to request a consultation with Dr. Stewart?Who referred you to us?Address:PhoneWhat other facts do you think will be helpful?Payment Policy*Payment is reqiured at the time services are rendered.Agree ONLINE FORMS Dermatology History Policy Agreement Veterinarian Referral View PDF Version of this Form