SACDERMVET HISTORY FORM FOR NEW CLIENTS

SACDERMVET HISTORY FORM FOR NEW CLIENTS

Please complete as best you can before your first appointment
Owner's Name - Last, First*
SPOUSE / PARTNER
Address*
City, State & Zip*
Cell Phone*
We may text appointment reminders
Home Phone
Work Phone
E-mail
We use email for communication so enter one you check regularly.
Owner Occupation
Owner Employer
Partner Cell Phone
Partner Work Phone
Partner Occupation
Partner Employer
Payment Method*
Payment required at time of service. SDV does not accept Amex or Care Credit
Pet's Name*
Species*
Gender*
Breed*
Colour*
DOB or Age*
Approximate is OK
Your Vet's Name
Vet Clinic & Address
We will contact your local clinic for records
Reason for Visit*
What is your main concern about your pet today?
How long have you owned this animal*
Acquired from?*
Are they now a*
Past Illnesses*
Include reactions to medications
Date of Last Rabies vaccine*
Date of Last Parvo vaccine*
General History
Is their weight?*
Is their appetite?*
What do they eat?*
Brand and variety if known
Any Treats?*
Has diet been changed*
If Yes. What was previous diet and when was it changed?
Water Consumption*
Volume of Urine*
Urine frequency*
Vomiting?*
Diarrhoea?*
Lameness or Limping*
Cough or Sneeze?*
Tire Easily?*
Trouble Breathing*
Ever Anxious or Nervous?*
Ever Fearful or Aggressive?*
Any unusual, fearful aggressive or anxious behaviours?
Breeding status*

NeuteredIntactUnknown
If Female is she?
Are oestrus ( heat) cycles regular?
Any False pregnancies?
Eye Discharge?*
Shake their head?*
Scratch their ears?*
If bother ears?

Both earsLeft earRight ear
Ear Odour or Discharge*
Any Hearing or Balance problems?*
Do they live?*
Where do they sleep & usual bedding?*
How often are they bathed?*
How often do they swim?*
What shampoo is used?*
Shampoo and conditioner if used
Do any parents or siblings have skin problems?*
Do you have other animals?*
Do those other animals have skin problems?*
Do any humans in the household have skin problems?*
If so, please give details
Does this animal have close contact with any immune compromised persons?*

NoYesUnsure
If so any details
SPECIFIC DERMATOLOGICAL HISTORY
When did they first have a skin or ear problem?*
When did the present episode of skin or ear problems start?*
Did the current problem start?*

SlowlyRapidlyUnknown
Is there any itchiness?*

NoYes
If itchiness is it?
Itch overnight?*
Rub their face?*
Lick or chew paws?*
Itch other areas?*
Were signs every seasonal?*
If ever seasonal, when were they worse?

SpringSummerAutumnWinter
Any external parasites seen in last 18 months?*

NoneFleasTicksOther Bites or Stings
External parasites on other animals in household?

NoneFleasTicksOther Bites or stings
Flea control this pet?*
Flea control other dogs?*
Flea control other cats?*
Heartworm prevention?*
What was the first change you noted?*
Please describe and include where on body
Please describe the changes in skin or ears as condition progressed*
What worsens the condition?*
What improves the condition?*
What do you think caused it?*
Medications used in the last 12 months for skin or ears

Please give name, dose (mg), frequency if known. Also any response or reaction.
Medications by mouth*
By Injection*
Steroids or antibiotics or Cytopoint (CADI)
Ear Drops*
Ear cleaner*
Creams ointments*
Sprays*
Supplements*
Please click Submit when finished to email us this form
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SACDERMVET HISTORY FORM FOR NEW CLIENTS

General History

SPECIFIC DERMATOLOGICAL HISTORY

Medications used in the last 12 months for skin or ears