Dermatology History Form printable pdf download

Dermatology

history form

[Patient label information here]

Date _______________________________________________________

Your name _________________________________________________

1. What skin or ear problem are you bringing your pet in for? ______________________________________________________

2. How long has the problem been present? __________ How old was your pet when the problem first started? __________

3. When the problem started, did it come on suddenly or gradually over a period of time? ____________________________

4. What did the skin or ear problem look like initially? _____________________________________________________________

5. How has it changed or spread? ______________________________________________________________________________

6. The problem has been (check one):

Continual, even with medication

Continual but better with medication

Intermittent or sporadic

7. Is the problem worse during certain times of the year? If so, when? ______________________________________________

8. Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease? Use a scale of

1 to 10 with 1 meaning an occasional scratch, like a normal person or animal might do, and 10 meaning constant,

severe scratching. __________________________________________________________________________________________

9. Using the same 1 to 10 scale, how itchy has your pet been over the past month? _________________________________

10. Is your pet receiving any treatment now? If yes, what kind? _____________________________________________________

11. When did your pet last receive any medication, and what medication was it? ______________________________________

12. What do you feed your pet now? _____________________________________________________________________________

13. Have any different diets been tried as treatment? If so, list the brand name and for how long you fed it: ______________

______________________________________________________________________________________________________________

14. How often do you usually bathe your pet? With what? __________________________________________________________

15. When was the last time you saw a flea on your pet or another pet in the household? _______________________________

16. Do you routinely use flea or tick preventive products on your pet (list type)? ______________________________________

17. How old was your pet when you obtained him/her? Where did you get your pet? _________________________________

18. What other pets are in the household? _______________________________________________________________________

19. Do any of the other pets have skin problems? Do any people in the household have skin problems? ________________

20. What percentage of the day and night does your pet spend indoors vs. outdoors? Indoors ____% Outdoors ____%

21. Other than skin disease, does you pet have any diagnosed medical problems? ____________________________________

22. Please list any other clinical signs your pet has that have not been described above or anything else you suspect might

be contributing to your pet’s skin or ear disease? ______________________________________________________________

Please turn over and continue on reverse side.

Dermatology History Form