Patient History Form

For Dermatology re-check appointments.

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Owner's Name(Required)

Patient's Name

Patient's Weight

How has your pet’s skin/ear problem changed since their previous visit?(Required)

How itchy/uncomfortable is your pet since their previous visit?

Please list the areas that are most affected/itchy/bothersome at this time:

What food(s) does your pet eat, including pet food, treats, and "human foods"?

Please list any medications that your pet has received since the previous visit.

Be sure to include prescription and over-the counter oral medications, injectable medications, vitamins/supplements, heartworm/flea/tick prevention products, topical ear medications, shampoos, and any sprays/creams/ointments.

Medication Name Dose Frequency Helpful? (Y/N)

Additional Medication Details

Please any additional details we should be aware of per your pet's current or previous medications.

Does your pet experience any of these problems? Check all that apply.

Vomiting

Excessive Thirst

Diarrhea

Lethargy

Weight Gain/Weight Loss

Seizures

Excessive/Frequent Urination

Runny Eyes

Is there anything else you would like us to know about your pet or family?

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Phone

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