Dermatology history form | Study notes Dermatology

1. What skin or ear problem are you bringing your pet in for? ______________________________________________________

2. How long has the problem been present? __________ How old was your pet when the problem first started? __________

3. When the problem started, did it come on suddenly or gradually over a period of time? ____________________________

4. What did the skin or ear problem look like initially? _____________________________________________________________

5. How has it changed or spread? ______________________________________________________________________________

6. The problem has been (check one):

Continual, even with medication Continual but better with medication Intermittent or sporadic

7. Is the problem worse during certain times of the year? If so, when? ______________________________________________

8. Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease? Use a scale of

1 to 10 with 1 meaning an occasional scratch, like a normal person or animal might do, and 10 meaning constant,

severe scratching. __________________________________________________________________________________________

9. Using the same 1 to 10 scale, how itchy has your pet been over the past month? _________________________________

10. Is your pet receiving any treatment now? If yes, what kind? _____________________________________________________

11. When did your pet last receive any medication, and what medication was it? ______________________________________

12. What do you feed your pet now? _____________________________________________________________________________

13. Have any different diets been tried as treatment? If so, list the brand name and for how long you fed it: ______________

______________________________________________________________________________________________________________

14. How often do you usually bathe your pet? With what? __________________________________________________________

15. When was the last time you saw a flea on your pet or another pet in the household? _______________________________

16. Do you routinely use flea or tick preventive products on your pet (list type)? ______________________________________

17. How old was your pet when you obtained him/her? Where did you get your pet? _________________________________

18. What other pets are in the household? _______________________________________________________________________

19. Do any of the other pets have skin problems? Do any people in the household have skin problems? ________________

20. What percentage of the day and night does your pet spend indoors vs. outdoors? Indoors ____% Outdoors ____%

21. Other than skin disease, does you pet have any diagnosed medical problems? ____________________________________

22. Please list any other clinical signs your pet has that have not been described above or anything else you suspect might

be contributing to your pet’s skin or ear disease? ______________________________________________________________

Date _______________________________________________________

Your name _________________________________________________

Please turn over and continue on reverse side.

Dermatology

history form

[Patient label information here]

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1. What skin or ear problem are you bringing your pet in for? ______________________________________________________ 2. How long has the problem been present? __________ How old was your pet when the problem first started? __________ 3. When the problem started, did it come on suddenly or gradually over a period of time? ____________________________ 4. What did the skin or ear problem look like initially? _____________________________________________________________ 5. How has it changed or spread? ______________________________________________________________________________ 6. The problem has been (check one):

Continual, even with medication Continual but better with medication Intermittent or sporadic

7. Is the problem worse during certain times of the year? If so, when? ______________________________________________ 8. Over the past year, how itchy has your pet been during a typical outbreak of skin or ear disease? Use a scale of 1 to 10 with 1 meaning an occasional scratch, like a normal person or animal might do, and 10 meaning constant, severe scratching. __________________________________________________________________________________________

9. Using the same 1 to 10 scale, how itchy has your pet been over the past month? _________________________________

10. Is your pet receiving any treatment now? If yes, what kind? _____________________________________________________ 11. When did your pet last receive any medication, and what medication was it? ______________________________________ 12. What do you feed your pet now?_____________________________________________________________________________ 13. Have any different diets been tried as treatment? If so, list the brand name and for how long you fed it: ______________

14. How often do you usually bathe your pet? With what? __________________________________________________________ 15. When was the last time you saw a flea on your pet or another pet in the household? _______________________________ 16. Do you routinely use flea or tick preventive products on your pet (list type)? ______________________________________ 17. How old was your pet when you obtained him/her? Where did you get your pet? _________________________________ 18. What other pets are in the household? _______________________________________________________________________ 19. Do any of the other pets have skin problems? Do any people in the household have skin problems? ________________ 20. What percentage of the day and night does your pet spend indoors vs. outdoors? Indoors ____% Outdoors ____% 21. Other than skin disease, does you pet have any diagnosed medical problems? ____________________________________ 22. Please list any other clinical signs your pet has that have not been described above or anything else you suspect might be contributing to your pet’s skin or ear disease? ______________________________________________________________

Date _______________________________________________________ Your name _________________________________________________

Please turn over and continue on reverse side.

Dermatology

[Patient label information here] history form

23. In the following table, check which clinical signs have been present and how severe they have been over the entire course of the pet’s skin or ear problem. (Check one box for each clinical sign.)

Clinical sign Never occurs or none occurs rarely or slight occurs occasionally or moderate occurs often or severe Scratching/licking/biting at self Hair loss or poor regrowth of hair Increased redness to skin Small red spots, pimples, bumps, rash Dandruff, flakiness, scaliness of skin Increased odor of skin or coat Crusty or scabby patches on skin Open, raw sores Areas that ooze blood or pus Eyes—redness, irritation, itching, discharge Change in color or texture of hair Darkening of areas of the skin Loss of pigment of skin—black parts turn pink Ear infections Fleas seen on pet Diarrhea or loose stools Vomiting Sneezing or wheezing Changes in pet’s usual personality Changes in pet’s usual activity level Weight loss or weight gain Changes in pet’s appetite Changes in amount of water consumed Changes in urinary habits

24. How much licking, biting, chewing, scratching, or rubbing does your pet do on the following areas of the body? (Check one box for each clinical sign.)

Body area Not itchy mildly itchy moderately itchy severely itchy Feet/paws Legs/arms Abdomen (belly)/genital area Armpits/chest/sides of body Face/eyes Ears/ear flaps Along the back or rump The tail itself Anal area

25. It is important that we know which types of medications were given to your pet in the past and whether they helped. On the list of medications below, check if they have been given and, if so, how much relief they produced. (Check box “Yes” if given and then how much the treatment helped.)

treatment or medication Was it ever given? if given, how much did it help? yes No Not sure Did not help helped some helped a lot Cortisone pills or shots (steroids, Temaril, prednisone, Vetalog, anti-itch pills) Antibiotics alone (with no other medication given at the same time) Antihistamine (Benadryl, Zyrtec, etc.) Antifungal medications (ketoconazole, etc.) Cyclosporine (Atopica) Apoquel Allergy shots or drops

Dermatology history form, Study notes of Dermatology

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Dermatology

[Patient label information here] history form