Dermatology History Form

For Dermatology patients’ initial visit.

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Owner's Name(Required)

Patient's Name

Patient's Weight

What is the primary dermatologic problem or reason for your visit today?(Required)

How long has the current problem been present?(Required)

Does your pet have a history of skin/ear issues prior to this problem?(Required)

Is this problem worse at certain times of the year or has it been constant throughout the year?(Required)

If this problem fluctuates, when is it worse? And best?

How itchy/uncomfortable your pet has been at its worst?

How itchy/uncomfortable is your pet today?

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

Has your pet traveled beyond Kentucky, Ohio, or Indiana? If yes, please list:

Do you have other pets in the home? If yes, please list:

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

Has your pet ever eaten a diet prescribed by your veterinarian? If yes, please list the brand of the food and approximately how long it was fed to your pet:

Please list any medications that your pet is currently receiving or has received while being treated for this problem.

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

Does your pet have any previously diagnosed health problems?

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Name

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