Dermatology Clinic for Animals Las Vegas--Patient History Form

Dermatology Clinic for Animals Las Vegas
Patient History

Pet Name:	Client's Name:
1. Chief Complaint(s)
2. Age of pet when you acquired him/her:
Age now:
3. Approximate date when problem first started:
4. Is it seasonal or continuous? Seasonal Continuous
5. Was the problem initially seasonal? Yes No
6. Is there a time when the disease is less severe or the itching is less intense?
7. What did the problem look like initially? (Please check) Normal skin, just itchy Hair loss Rash Pimples Redness
8. Where did it start? (Please check) Nose Eyes Ears Neck Back Rump Tail Front paws Back legs Back paws Chest Abdomen Groin
9. Has it spread? Yes No If so, where?
10. Does your pet scratch, rub, chew, lick, or bite the following (Please check) Nose Muzzle Eyes Ears Neck Back Rump Tail Armpits Front legs Back legs Thighs Back paws Front paws Chest Abdomen Groin
11. Was the itching the first thing noticed? Yes No
12. Do you have other pets? Yes No If yes, describe:
13. Do any have skin problems? Yes No If yes, explain:
14. Do any people in the household have skin problems? Yes No If yes, describe:
15. Percent of time pet is confined indoors? Outdoors?
16. What is your primary indoor flooring surface? Carpet Tile Wood Other :
If carpeting, does it contain wool? Yes No
17. What is your dog's outdoor environment? (Check all that apply) Grass Rock Dirt Cement Outdoor Carpeting Pool Other:
18. Where/when are symptoms the worst? Indoors Outdoors Night Morning
19. If a female, are or were there normal heat cycles? Yes No
20. If a male, does he have normal interest in females? Yes No
21. Do any relatives of your pet have any skin problems that you are aware of? Yes No If yes, explain:
22. Do you use flea control? Yes No If yes, check which ones used: Powder Dips Sprays Collars Baths Spot-ons What brands? Frequency?
23. Do you use insecticides in your home? Yes No Frequency?
24. Please check medications that your pet has been on for the problem: Antihistamines Steroid pills Steroid shots Antibiotics Other:
25. Did any help the problem? Yes No If yes, which?
26. Any other medications, vitamins, food supplements?
27. What is your pet’s regular diet?
28. Does your pet have any other health problems? (Please check) Cough Sneeze Runny eyes Vomiting Diarrhea Tires easily Limps Drinks excessively Urinates excessively
29. How often do you bathe your pet?
What shampoo and/or conditioner do you use?

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