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
*
Please Select
VisaCard
Mastercard
DiscoverCard
Cheque
Cash
Payment required at time of service. SDV does not accept Amex or Care Credit
Pet's Name
*
Species
*
Please Select
Dog
Cat
Gender
*
Please Select
Female Neutered
Female
Male Neutered
Male
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?
*
Please Select
Breeder
Family or Friend
Pet Shop
Rescue or Shelter
Are they now a
*
Please Select
Pet
Breeding or Show Animal
Service Animal
Working or Hunting Animal
Past Illnesses
*
Include reactions to medications
Date of Last Rabies vaccine
*
Date of Last Parvo vaccine
*
General History
Is their weight?
*
Please Select
Stable
Increasing
Decreasing
Unknown
Is their appetite?
*
Please Select
Normal
Increased
Decreased
Unknown
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
*
Please Select
Normal
Increased
Decreased
Unknown
Volume of Urine
*
Please Select
Normal
Increased
Decreased
Unknown
Urine frequency
*
Please Select
Normal
Increased
Decreased
Unknown
Vomiting?
*
Please Select
No
Yes
Sometimes
Unknown
Diarrhoea?
*
Please Select
No
Yes
Sometimes
Unknown
Lameness or Limping
*
Please Select
No
Yes
Sometimes
Unknown
Cough or Sneeze?
*
Please Select
No
Yes
Sometimes
Unknown
Tire Easily?
*
Please Select
No
Yes
Sometimes
Unknown
Trouble Breathing
*
Please Select
No
Yes
Sometimes
Unknown
Ever Anxious or Nervous?
*
Please Select
No
Yes
Sometimes
Unknown
Ever Fearful or Aggressive?
*
Please Select
No
Yes
Sometimes
Unknown
Any unusual, fearful aggressive or anxious behaviours?
Breeding status
*
Neutered
Intact
Unknown
If Female is she?
Please Select
Pregnant
Not Pregnant
Uncertain
Are oestrus ( heat) cycles regular?
Please Select
No
Yes
Unknown
Any False pregnancies?
Please Select
No
Yes
Unknown
Eye Discharge?
*
Please Select
No
Yes
Sometimes
Shake their head?
*
Please Select
No
Yes
Sometimes
Scratch their ears?
*
Please Select
No
Yes
Sometimes
Unknown
If bother ears?
Both ears
Left ear
Right ear
Ear Odour or Discharge
*
Please Select
No
Yes
Sometimes
Any Hearing or Balance problems?
*
Please Select
No
Yes
Sometimes
Do they live?
*
Please Select
Inside only
Mostly inside
Mostly outside
Outside only
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?
*
No
Yes
Unsure
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?
*
Slowly
Rapidly
Unknown
Is there any itchiness?
*
No
Yes
If itchiness is it?
Please Select
Mild
Moderate
Severe
Extreme
Itch overnight?
*
Rub their face?
*
Lick or chew paws?
*
Itch other areas?
*
Were signs every seasonal?
*
Please Select
No
Still are
Initially
Unknown
If ever seasonal, when were they worse?
Spring
Summer
Autumn
Winter
Any external parasites seen in last 18 months?
*
None
Fleas
Ticks
Other Bites or Stings
External parasites on other animals in household?
None
Fleas
Ticks
Other Bites or stings
Flea control this pet?
*
Please Select
None used
Activyl
Advantage
K9 Advantix
Advantage Multi
Bravecto
Cheristin for cats
Comfortis or Accuguard
Credelio
Frontline
Nexgard
Revolution Paradyne
Sentinel
Seresto collar
Simparica
Simparica Trio
Trifexis or Comboguard
OTC Pet store
Vectra
Other
Flea control other dogs?
*
Please Select
No Other Dogs
None used
Activyl
Advantage
K9 Advantix
Advantage Multi
Bravecto
Comfortis or Accuguard
Credelio
Frontline
Nexgard
Revolution or Paradyne
Sentinel
Seresto collar
Simparica
Simparica Trio
Trifexis or Comboguard
OTC Pet store
Vectra
Other
Flea control other cats?
*
Please Select
No other cats
None used
Advantage
Advantage multi
Cheristin for cats
Comfortis or Accuguard
Frontline
Revolution Paradyne
Seresto collar
Vectra for cats
OTC Pet store
Other
Heartworm prevention?
*
Please Select
None used
Advantage multi
Bravecto plus for cats
Heartgard
Interceptor
Iverheart TriHeart
ProHeart injection at Vet
Revolution Paradyne
Sentinel
Simparica Trio
Trifexis
Other
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
*
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