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Dermatology History Form

Client Name*
Patient
Age
Breed
Sex
Spayed or Neutered
- Y
- N
Date
MM slash DD slash YYYY
CHIEF COMPLAINT(S)
Age your pet was obtained
From where
Age when problem first noticed
Onset:
- Sudden
- Slow
Does the animal itch?
- Yes
- No
When?
- Constant
- Sporadic
- Night
Is there a seasonal influence?
- No
- Spring
- Summer
- Fall
- Winter
Where on the body did the problem begin?
What did it look like then?
What other animals do you own? Describe
Do ther animals or people in the household have skin problems, rash?
Describe the animal's indoor environment, time (%)
Describe the animal's outdoor environment, time (%)
What diagnostic tests have been performed?
What topical treatment has been used? Success?
What oral or injectable treatment(s) has been used? Success?
Do you have any thoughts as to the cause? What makes it worse?
When was the last time you saw fleas on any of your pets?
Describe your flea control
Animal's diet (including snacks & treats)
Medical history: previous diseases, treatments, results
Is the animal on any medications at present?
- Yes
- No
Which ones?
What other facts do you think would be helpful?
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