Date: MM slash DD slash YYYY Your Name:*Patient Name:*Veterinarian and Hospital that normally cares for your pet:*Please bring all current/recent medications, shampoos, supplements to your appointment. Please do not bathe your pet or clean your pet’s ears within 48hrs of your appointment. Please fill out this form as completely as possible:Current IssueWhat is the primary dermatologic problem/reason for your appointment today?*How long has the problem been present?Has your pet had a history of skin or ear issues prior to when the current problem started?Is your pet itchy (biting/licking/chewing/scratching/rubbing)?YesNoIf your pet is itchy, please grade the degree of irritation on a scale from 1-10:(minimal) 12345678910 (severe)Is the skin/ear problem worse or more severe at a certain time of the year, or is it the same throughout the year?If worse at a certain time of year, what time of year is it worse?Is the problem worse/better indoors versus outdoors?Has your pet traveled outside of the state?*YesNoWhen was their travel?Where was their travel?Do you have any other pets?YesNoPlease list species (cat, dog, etc) and number here.Do any of your other pets have skin problems?YesNoPlease describeDiet InformationWhat is the Brand name, flavor, type (canned, wet, etc) of food that you feed your pet?*How long have you been feeding this diet?What supplements/vitamins do you give your pet?List any snacks or treats (including human food) that you give your pet.Medication InformationPlease list all medications that your pet is currently receiving, or has received in the past 2 weeks, including all medications, supplements, and vitaminsMedication NameDoseFrequencyHelpful (Y/N)? Has your pet ever had a reaction to any medication?YesNoIs your pet on flea control?YesNoWhat type/frequency?Is your pet on heartworm prevention?YesNoWhat type of heartworm prevention?How often is your pet bathed/groomed?What shampoo is used?Does your pet have any other illnesses or major medical history?YesNoPlease list any other illnesses or major medical historyDoes your pet do/have any of the following excessively: Cough Sneeze Runny eyes Vomit Diarrhea Urinate Drink Water Are there any other concerns that we should be aware of with your pet today?* Δ