Dermatology history form

Please complete this form and bring it along at the time of your visit. OWNER’S NAME___________________________________ PET’S NAME:_____________________________________ Chief Complaint(s) ____________________________________________________________________________________ How old was your pet when the problem first started? _______________________________________________________
Was the onset: sudden__________ or gradual? ____________ Is the problem continuous (year-round)? YES______ NO_____ Does it have a seasonal pattern? YES______ NO______ If seasonal, when? SUMMER______ FALL_______ WINTER_______ SPRING_______ If it is continuous, was it ever seasonal? YES____ NO____
What was the problem like initially? (Scales____Itch____ Hair loss____ Rash____ Pimples____ Redness____Blisters_____
Other Lesions?__________________________________________ Where did it start? Nose____ Eyes____ Ears____ Neck____ Back____ Rump____ Tail____ Front legs____ Front
Paws____ Rear legs____ Rear paws____ Chest____ Abdomen____ Groin____ Armpit____Other___________________ Did it spread? ________; if so, from where__________________________to where? ______________________________ Does your pet scratch, rub, chew, lick, or bite any of the following areas? Nose____ Eyes____ Ears____ Neck____ Back____ Rump____ Tail____ Front legs____ Front Paws____ Back legs____ Back paws____ Chest____ Has there been any unusual odor associated with the condition? YES___ NO___ (please describe)____________________
____________________________________________________________________________________________________ Color change of hair? YES____ NO____ (please describe)_____________________________________________________ Color change of skin? YES____ NO____ (please describe) _____________________________________________________ Change of texture of skin or hair? YES____ NO____ (please describe)___________________________________________ What other pets do you have? ____________________________________________________________________________ Do any other pets or people in the household have skin problems?_______________________________________________ Have you seen Fleas_____ Ticks______ Lice_______ on your pet? Not ever? ________ What flea control do you use: ON YOUR PETS __________________________ IN YOUR HOUSE___________________? IN YOUR YARD________________________________? What brand(s) of food does your pet eat? Dry:__________________________ Canned:____________________________ Treats? ________________________ Vitamins or supplements? __________________________________ Do you feed any “people food”? (please describe)___________________________________________________________ What type of heartworm preventative do you use? ____________________________________________________________ How often do you bathe your pet (include professional grooming)? ______________________________________________ What type of shampoo? _________________________ When was the last bath given?___________________________ Has there been a change in frequency, urgency, or volume of urination (please describe)?_____________________________ Has there been a change in water intake (please describe)? ____________________________________________________
Has there been a change in activity level (please describe)? ____________________________________________________
Has there been a change in behavior (please describe)? _______________________________________________________
Has there been a change in bowel habits or stool consistency (please describe)_____________________________________
Has there been a change in appetite (please describe)? ________________________________________________________
Has your pet had any gastrointestinal problems (vomiting, diarrhea, etc)? ________________________________________
Have you used any home remedies or over-the-counter products for this condition? _______________________________
Did any of them improve the condition? Which ones? _______________________________________________ Has your pet received steroids (cortisone, prednisone, depo-medrol)?<(6___12____:KLFKRQHV"____________________
Response: BETTER_____ WORSE_____ NO CHANGE_____ Has your pet received antihistamines (benadryl, atarax, chlorpheniramine, etc.)?<(6BBB12BBBB:KLFKRQHV"
Response: BETTER_____ WORSE_____ NO CHANGE_____ Has your pet received any other drugs or treatments (please describe)?<(6BBB12BBBB:KLFKRQHV"__________________
Response: BETTER_____ WORSE_____ NO CHANGE_____ Is your pet currently on any medication(s), specialty diets, topicals, or over-the-counter products for this or any other condition not already described? __________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Are there any other comments or concerns? _________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

Source: http://alburtisanimalhospital.com/clients/6206/documents/DERM_HISTORY_FORM%20-%20fill-in.pdf