Dermatologic History Form - Animal Health Clinic of Funkstown

Owners Name*

First Last

Date*

Pet’s Name*

Age*

Breed*

Sex*

Male
Female

Spayed or Neutered?*

Yes
No

Please describe the main problem with your pet’s skin, ear, nails?*

Where did you obtain your pet?*

Shelter
Pet store
Breeder

At what age did you first notice the problems?*

Did the problem start*

Suddenly
Gradually

Does your pet itch or lick excessively or over groom (cats)*

Yes
No

How often?*

Constantly
Off and on throughout the day
When left alone
During the night

Rate itching from 1-10 (1 only occasionally ; 10 constant day and night)*

When is the problem the worst?*

Where on your pet’s body did the problem first begin?*

What did it look like at first?*

What other pets are in the household?*

Do the other pets or people in the household have itching, skin problems, rash?*

Where does your pet spend most of their time?*

Indoors
Outdoors

Does your pet swim?*

Yes
No

How often?*

Do you or your groomer bathe your pet?*

Yes
No

How often and with what product(s)?*

What shampoos, sprays, creams or ear medication and cleaners have you used? Which worked best?*

What pills or injections have you tried? Which worked best?*

When was the last time fleas were seen on any of your pets?*

What products do you use?*

Which pets are treated?*

Are all the pet treated at the same time? Do you use preventative all year round or seasonally?*

Describe your pet’s diet? (include food brand(s), snacks, and treats)*

Does your pet have any other medical problems?*

Has there been any change in your pet’s behavior since the skin or ear problems started? (ex. Change in energy, body weight, drinking, urinating, change in bowel movements)*

What do YOU think is causing your pet’s skin problems?*

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 3 days of the appointment.

Name

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