Patient History Form in Lacey, WA | Dermatology Clinic for Animals

Pet's Name*

Client's Name*

Chief Complaint

Age of pet when you acquired him/her:

Age now:

Approximate date when problem first started:

Is it seasonal or continuous?

Seasonal
Continuous

Was the problem initially seasonal?

Yes
No

Is there a time when the disease is less severe or the itching is less intense?

What did the problem look like initially? (Please check)

Normal skin, just itchy
Hair Loss
Rash
Pimples
Redness

Where did it start? (Please check)

Has it spread?

Yes
No

If so, where?

Does your pet scratch, rub, chew, lick, or bite the following? (Please check)

Was the itching the first thing noticed?

Yes
No

Do you have other pets?

Yes
No

If yes, please describe:

Do any have skin problems?

Yes
No

If yes, please describe

Do any people in the household have skin problems?

Yes
No

If yes, please describe:

Percent of time pet is confined indoors?

Outdoors?

What is your primary indoor flooring surface?

Carpet
Tile
Wood

If carpeting, does it contain wool?

Yes
No

Where/when are symptoms the worst?

If a female, are or were there normal heat cycles?

Yes
No

If a male, does he have normal interest in females?

Yes
No

Do any relatives of your pet have any skin problems that you are aware of?

Yes
No

If yes, explain:

Do you use flea control?*

Yes
No

If yes, check which ones used:

Powders
Baths
Dips
Sprays
Collars
Spot-Ons

What brands?

Do you use insecticides in your home?

Yes
No

Frequency?

Please check medications that your pet has been on for the problem:

Antihistamines
Apoquel
Cytopoint
Antibiotics
Steroid Pills
Steroid Shots
Other

Did any help the problem?

Yes
No

If yes, which?

Any other medications, vitamins, food supplements?

What is your pet’s regular diet? (Brand, Ingredients)

Does your pet have any other health problems? (Please check)

Cough
Sneeze
Runny Eyes
Vomiting
Diarrhea
Limps
Tires Easily
Drinks excessively
Urinating execessively

How often do you bathe your pet?

What shampoo and/or conditioner do you use?

Is your pet exposed to tobacco smoke?

Yes
No
Daily
Weekly
Rarely

Comments

I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.

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