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* Color Weight (lbs)* Animals Age:* Date of Birth* MM slash DD slash YYYY How long have you owned your pet? Where did you obtain your pet? Date of Last Booster Vaccine: MM slash DD slash YYYY Date of last Rabies Vaccine: MM slash DD slash YYYY Date the skin problem was first noticed: 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?* 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 ONLINE FORMS Dermatology History Policy Agreement Veterinarian Referral View PDF Version of this Form
