New Patient History Form

Client Name*

First NameLast Name
Phone Number *
Email Address *
Patient Name*
How old is your pet?*
How long have you owned him/her?*
Where was your pet obtained (i.e. shelter, breeder, friend, etc.)?*
Does your pet have pet insurance?*

YesNo
If yes, list company*
What is the primary reason for today’s visit?*
How old was your pet when the condition first occurred?*
What did you first observe and how has this changed over time?*
When the problem first started, it*

was sudden in onsetdeveloped more gradually over time
Is your pet itchy (licking, chewing, scratching, scooting, over-grooming)?*

YesNo
On a scale of 0-10, with 0 being “no itch” and 10 being “severe, constant itch”, how would you score your pet’s itch level today?*
On a scale of 0-10, what is your pet’s itch level during a typical outbreak of skin/ear disease?*
Which part(s) of the body is/are affected?*

EarsEyesFace/MuzzleNeckArmpitsFeet/PawsGroin/BellyBackUnder tail
Was there or is there a seasonal pattern to the itch?*

YesNo
If seasonal, during which seasons is your pet most affected?*

SpringSummerFallWinter
Is the problem worse when your pet is:*

IndoorsOutdoorsNot affected by this factor
What percentage of time does your pet spend indoors?*
What percentage of time does your pet spend outdoors?*
Has your pet ever had an ear infection?*

YesNo
If yes, when was the last infection?*
What is your pet’s current diet?*
What is your pet's current diet?*

DryCannedOther
What treats are provided (biscuits, rawhide/pig ears, hooves, bones, table food)?*
Do you brush your pet’s teeth?*

YesNo
Has a special diet been tried in the past?*

YesNo
If yes, please list diets*
How many bowel movements does your pet have per day?*
Do you have other pets at home?*

YesNo
Do other animals or people in the house have lesions/itching?*

YesNo
Is your pet exposed to other animals or wildlife (dog parks, boarding, groomer, woods)?*

YesNo
Which medications has your pet been treated with?*

ApoquelCytopointSteroids (prednisone, dexamethasone, Depo Medrol)Atopica (cyclosporine)Antibiotics (cephalexin, Simplicef, Convenia, Clavamox, Baytril)Antifungals (ketoconazole, fluconazole, terbinafine)Antihistamines (Benadryl, Zyrtec, hydroxyzine)Fatty acids/fish oilEar medicationOther
Which medications is your pet currently receiving?*

ApoquelCytopointSteroids (prednisone, dexamethasone, Depo Medrol)Atopica (cyclosporine)Antibiotics (cephalexin, Simplicef, Convenia, Clavamox, Baytril)Antifungals (ketoconazole, fluconazole, terbinafine)Antihistamines (Benadryl, Zyrtec, hydroxyzine)Fatty acids/fish oilEar medicationOther
Which, if any, of these medications have helped the problem?*

ApoquelCytopointSteroids (prednisone, dexamethasone, Depo Medrol)Atopica (cyclosporine)Antibiotics (cephalexin, Simplicef, Convenia, Clavamox, Baytril)Antifungals (ketoconazole, fluconazole, terbinafine)Antihistamines (Benadryl, Zyrtec, hydroxyzine)Fatty acids/fish oilEar medicationOther
Is your pet’s condition*

Continuous but better with medicationContinuous but not better with medicationIntermittent or sporadic
Do you give your pet any vitamins, oils, or supplements?*

YesNo
If yes, please list*
Do you currently bathe your pet?*

YesNo
If yes, how often?*
If yes, what is the name of the shampoo?*
Do you currently clean your pet’s ears?*

YesNo
If yes, how often?*
What is the name of the ear cleaner?*
If applicable, does your dog swim?*

YesNoNot applicable
If yes, how frequently?*
Is your pet currently on heartworm prevention?*

YesNo
If yes, which product?*
If yes, when was the product last given?*
Is your pet currently on flea and tick prevention?*

YesNo
If yes, which product?*
If yes, when was this product last given?*
Have you noticed any fleas or ticks?*

YesNo
Does your pet have any known adverse/allergic reactions to medications or vaccinations?*

YesNo
If yes, please list*
Other than skin disease, does your pet have other diagnosed medical conditions?*

YesNo
If yes, please list*
Have you noticed any of these symptoms in the past six months?*

VomitingDiarrheaCoughingSneezingRunny EyesIncreased thirstIncreased urinationWeight lossWeight gainLethargy/inactivityIncreased appetiteDecreased appetiteOther
As part of our Fear-Free approach, we may offer your pet high value treats including whipped cream, peanut butter, pretzels, spray cheese, liver paste, and marshmallows. Is anything off limits?*

YesNo
If yes, please list*
Are there any nut allergies at home?*
Please check the box below before submitting the form.
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