Patient History Form

New Patient Form

Please complete both this and the new client form before your appointment - they will take approximately 20 minutes. If you prefer to fill out a pdf version, please contact us and we can send you a copy. If you wish to fill out these forms at our office, please arrive 30 minutes before your appointment or you may be asked to reschedule.
Date

MonthDayYear
Date
Patient Name
Owner Name
Email address:
example@example.com
General Medical History:
How old was your pet when he/she came to live with you?
Where did you get your pet (i.e. breeder, shelter, etc?
Has your pet always lived in Washington state (please circle one)?

YesNo
If no, please state where else they lived and when?
Does your pet have any other health problems?

YesNo
If yes, please least any other health problems your pet has.
Has your pet ever been sedated or anesthetized?

YesNo
If yes, has your pet ever had any problems under anesthesia?

YesNo
If yes, please list:
Does your pet ever bite or become aggressive in the vet's office?

YesNo
Please list your pet's flea medication
Date of last flea medication dose

MonthDayYear
Date
Please list your pet's heartworm medication
Date of last heartworm medication dose

MonthDayYear
Date
List ALL oral medications and supplements that your pet is currently taking:
List ALL topical medications that your pet is receiving (shampoos, sprays, wipes, oils, ear drops, etc.):
I am currently feeding my pet (name food type) blanks.
My pet has been eating this food for (write approximately length of time) blank.
If you changed food recently, when did you change and why?
List ALL treats/chews you are currently feeding your pet (table scraps, human food, treats, chews, bones, etc.):
Please note if you have difficulty doing any of the following at home

Bathing your petGiving pill medications by mouthApplying medications topicallyGiving injections under the skin (subcutaneously)Giving liquid medications by mouthOther
Dermatological History:
My pet is coming to a dermatologist because
How long has your pet had this problem?
How old was your pet when the problem started?
Is the problem continuous (year-round) or seasonal?

ContinuousSeasonal
If seasonal, what season(s) is your pet most affected?
When/Where are the symptoms worse? (check any that apply)

MorningNightIndoorsOutdoors
Where did you first notice the problem on your pet (i.e. paws, face, ears, etc.)?
Please check any of the following that you noticed when the problem started?

Normal skin, just itchyRed skinPimplesBlack HeadsDry skinSores/Hot spotsEar infectionHair lossFlaky skinScabs or crustsRashesOther
Please check any of the following that you are currently noticing.

Normal skin, just itchyRed skinPimplesBlack HeadsDry skinSores/Hot spotsEar infectionHair lossFlaky skinScabs or crustsRashesOther
Which of the following does your pet also do or have?

Eye discharge (goopy or runny eyes)Coughing or wheezingSneezingFrequent GassinessVomitingDiarrhea or soft stoolOther
How many bowel movements does your pet have on average each day?
How has your pet's water consumption changed in the last 6 months?

IncreasedDecreasedNo change
Does your pet go to dog parks, doggy daycare, or the groomer?

YesNo
If your pet is groomed, do symptoms get worse after grooming?

YesNo
How often do you bathe your pet?
Does bathing help?

YesNo
Do any people in the household or that visit often have skin problems/itching?

YesNo
If yes, please briefly describe:
Has your pet ever had an ear infection?

YesNo
If yes, how often do ear infections occur?
Do you clean your pet's ears?

YesNo
If yes, how often do you clean them?
Was your pet itchy when the problem started (i.e. scratching, licking biting, scooting, chewing)?

YesNo
Is your pet itchy now (i.e. scratching, licking, biting, scooting, chewing)?

YesNo
If yes, please check any of the following areas that are itchy.

Front pawsFront legsElbowsBack pawsBack legsTail/Rear endAbdomen/BellyGroin/Inner legsEarsChestBackNeckUnderarmsFace/MuzzleOther
Is your pet's itch seasonal?

YesNo
If yes, during what seasons is your pet most affected?
Should be Empty:

New Patient Form

General Medical History:

Dermatological History: