Fairmont Dermatology Form

Fairmont Dermatology Form

Patient history intake for dermatology concerns. Please answer all questions exactly as applicable.
Patient History Intake Questions
Chief complaints(s)
Age of pet when acquired
Current Age
Approx. date problem started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is condition
If problem is now continuous, was it initially seasonal?
Does your pet do any of the following? If yes, list frequency and description
List frequency and description
Indoors %
Outdoors %
Are symptoms worse
Describe
What was the problem like initially?
Where did problem start?
Has it spread?
If so, where?
Does your pet scratch, rub, chew, lick or bite any of the following areas?
How itchy is your pet on a scale of 1 - 10 (10 being the worst possible)?
1-10 Comments
If yes, explain
Does your pet do any of the following? If yes, list frequency and description
For each symptom, list frequency and provide a description.
Do you have other pets affected in the household?
If yes, Describe
Do you or anyone in your household have skin problems?
If Yes, Describe
Flea Control and Medications
Do you use flea control on your pet?
Type
How Often?
Do you use environmental flea control in your home and/or yard?
If Yes, Frequency
Please list medication/injections your pet has taken for this skin/ ear condition
Other medications your pet is receiving
Did any medications help the problem?
If Yes, Which one(s)?
Please list any vitamins, food supplements, etc. your pet has been given
Diet, Bathing, and GI History
How often do you bathe your pet and what shampoos are used?
What is your pet’s current diet, including treats?
How long has your pet been on this diet?
Please circle the number of bowel movements your pet has per day
Has your pet received treatment for stomach or intestinal problems?
If yes, explain?
Should be Empty:

Fairmont Dermatology Form

Patient History Intake Questions

Flea Control and Medications

Diet, Bathing, and GI History