Dermatologic History Form Client Name:*Patient Name:*Date:* Date Format: MM slash DD slash YYYY Patient Age:*Breed:*Please describe the main problem with your pet’s skin, ears or nails. At what age was the problem first noticed?:*How old was your pet when you obtained him/her?:*Where did you obtain your pet?:*Do you know if any relative of your pet have skin or ear problems?:*How did the problem start:*SuddenlyGraduallyDoes your pet itch or lick excessively? Overgroom (cats)?:*YesNoIf yes, When?:*Constant?:*YesNoOn and off during the day?:*YesNoWhen left alone?:*YesNoDuring the Night?:*YesNoRate itching from 1 to 10 (1=occ. Itching, 10=itching continually all day/night):*When is the problem worse?:*No change with season:*SpringSummerFallWinterWhere on your pet’s body did the problem begin?:*What part of your pet’s body is most itchy?:*What did it look like at first? :*What other pets are in the household? :*How much time your pet spend indoors % ?:*How much time your pet spend outdoors % ?:*Do other pets or people in the household have itching, skin problems, rash?:*Where does your pet spend most of his/her time?:*For dogs only:*Yes it is a dog.No, it is not.Does your dog swim?:*YesNoHow Often?:*Do you or a groomer bathe your pet?:*How often?:*With what product?:*What shampoos, sprays, creams or ear medications/cleaners have you used?:*Which medication worked the best?:*What pills or injections have you used?:*Which medication worked the best?:*When was the last time fleas were seen on any of your pets?:*Describe your pet’s flea control – what product is used?:*When did you last apply the product?:*Are other pets treated at the same time?:*YesNoIs it year round?:*YesNoDescribe your pet’s diet (including name of food, snacks & treats):*Does your pet have other medical problems?:*Has there been any change in your pet’s behavior since the skin or ear problem started? (Ex. Change in energy level, body weight, drinking, urinating number/firmness of bowel movements):*Is your pet on any medications at the present?:*YesNoIf Yes, Please list:*What do you think is the cause of your pet’s skin problem?:*NOTE: Please bring all pills, ear drops, creams/ear cleaners, shampoos, sprays and any other products to the appointment – even if they are empty. Please do not bathe your pet within 5 days of the appointment or clean your pet’s ears within 2 days of the appointment.