Dermatology History Sheet
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).
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?
14. Which drug(s) helped most?
15. Comments that you feel may be helpful