Dermatology History Sheet

Patient                                                                                                         Date 


1. Briefly state the problem:
 
2. When was the problem first noted (Month & Year, please)? 

3. Is the problem year round? 
_____Yes, it has always been year round.
_____Yes, but it used to be seasonal (only part of the year).
_____No.
_____Unknown.

4. Are problems more severe during particular season(s)?     No    Yes ( Spring   Summer   Fall    Winter)

5. Is there scratching, chewing, licking or rubbing?     No        Yes

Is it:      Severe   or Constant       Moderate       Mild?

Where does your pet itch, chew, lick, or rub?       lower back       feet/legs      face     ears   belly     arm pits   all over      other
 
6. Where on the body did the problem begin? 

7. Are fleas currently present on any of your pets?     Yes        No       Maybe

 When did you last see a flea on any of your pets? 

 Do you give any medications to prevent fleas?     No     Yes, which product(s) do you use? 
 
How often do you administer it? 

 How often are ticks seen on your pet?      Never      Occasionally      Frequently

8. Do other pets that have contact with the patient have skin problems?      Yes      No      No contact with other animals.

9. Do littermates or the parents of the pet have skin problems?     Yes       No      Unknown

10. Have any people in the house developed skin problems?       Yes       No

11. How often do you shampoo your pet?                                    With what? 

12. How often do you clean your pet's ears?                                With what cleanser? 

13. Which medications have been used to treat the skin problem?

        DRUG                       HOW MUCH (mg)?                          HOW OFTEN?                        LAST GIVEN WHEN?                    DID IT HELP?

1.

2.

3.

4.




14. Which drug(s) helped most? 

15. Comments that you feel may be helpful





: