Dermatology History Form

Dermatology History Form
Date*

MonthDayYear
Date
Pet's Name*
What skin or ear problem are you bringing your pet in for?*
How long has the problem been present?
How old was your pet when it first started?
Did the problem come on

SuddenlyGradually over a period of time
What did the skin or ear problem look like initially?
How has it changed or spread?
The problem has been

Continual, even with medicationContinual, but better with medicationIntermittent or sporadicFirst time seeing this problem
Is the problem worse during certain times of the year?

YesNo
What time of the year is it worse?
Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease?

1

2

3

4

5

6

7

8

9

10

1 is occasional scratching, 10 is constant severe scratching
Using the same scale, how itchy has your pet been during the past month?

1

2

3

4

5

6

7

8

9

10

1 is occasional scratching, 10 is constant severe scratching
Is your pet receiving any treatment now?

YesNo
Please list any treatments your pet is on
When did your pet last receive each of any medications it is on? (please list medications as well as when they were given.

What do you feed your pet now?
Have any different diets been tried as a treatment?

YesNo
List the brand name of the food tried, and how long you fed the food.
How often do you bathe your pet?

NeverA few times a yearMonthlyMore than once per month
What do you use to bathe your pet?
When was the last time you saw a flea on your pet or on another pet in the household?

MonthDayYear
Date
Do you routinely use flea or tick preventive products on your pet?

YesNo
Which flea/tick products do you use?

BravectoRevolutionAdvantage/primidacideFlea collarPet store productOther
How old was your pet when you obtained him/her?
Where did you get your pet?
Are there any other pets in the household?

YesNo
Please list other pets
Do any of the other pets have skin problems?

YesNo
Do any people in the household have skin problems?

YesNO
What percentage of the day and night does your pet indoors vs outdoors? Indoors blanks %. Outdoors? blank %.
Other than skin disease, does your pet have any diagnosed medical problems?

YesNo
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 list all medical conditions of your pet.

In the following table, please check which clinical signs have been present and how severe they have been over the course of your pet's skin or ear problem. (check one box for each clinical sign

Rows	Never occurs, or none	Occurs rarely, or slight	Occurs occasionally , or moderate	Occurs often, or severe
Scratching/licking/biting at self
Hair loss or poor regrowth of hair
Increased redness to skin
Small red spots, pimples, bumps and/ or rash
Dandruff, flakiness, scaliness of skin
Increased odor of skin or coat
Crusty of scabby patches on skin
Open, raw sores
Areas that ooze blood or pus
Eyes - redness, irritation, itching, discharge
Change in colour or texture of hair
Darkening of areas of the skin
Loss of pigment of skin (dark skin turns pink)
Ear infections
Fleas seen on pet
Diarrhea or loose stools
Vomiting
Sneezing or wheezing
Changes in pet's usual personality
Changes in pet's usual activity level
Weight loss or gain
Changes in appetite
Changes in water consumption
Changes in urinary habits

How much licking, biting, chewing, scratching or rubbing does your pet do on the following areas of the body?

Rows	Not itchy	Somewhat itchy	Moderately itchy	Severely itchy
Feet/paws
Front or back legs
Abdomen (belly)/ genital area
Armpits/chest/sides of body?
Face/eyes
Ears/ear flaps
Along the back or rump
The tail itself
Anal area

It is important that we know which types of medications were given to your pet in the past and whether they helped. On the list of medications below, check if they have been given and, if so, how much relief they produced. (check box "yes" if given and then how much the treatment helped)

Rows	Yes	No	Unsure	No help	Helped some	Helped a lot
Cortisone pills or shots (steroids, temaril, prednisone, vancectyl P)
Antibiotics alone
Antihistamine (benedryl zyrtec etc)
Antifungal (ketoconazole etc)
Cyclosporin (atopica)
Apoquel
Allergy shots or drops
Cytopoint injections

Should be Empty: