Dermatology History Form Name*Date* MM slash DD slash YYYY What skin or ear problem are you bringing your pet in for?How long has the problem been present?How old was your pet when the problem first started?When the problem started, did it come on suddenly or gradually over a period of time?What did the skin or ear problem look like initially?How has it changed or spread?The problem has been (check one): Continual, even with medication Continual but better with medication Intermittent or sporadicIs the problem worse during certain times of the year? If so, when?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.Using the same 1 to 10 scale, how itchy has your pet been over the past month?Is your pet receiving any treatment now? If yes, what kind?When did your pet last receive any medication, and what medication was it?What do you feed your pet now?Have any different diets been tried as treatment? If so, list the brand name and for how long you fed it:How often do you usually bathe your pet? With what?When was the last time you saw a flea on your pet or another pet in the household?Do you routinely use flea or tick preventive products on your pet (list type)?How old was your pet when you obtained him/her? Where did you get your pet?What other pets are in the household?Do any of the other pets have skin problems? Do any people in the household have skin problems?What percentage of the day and night does your pet spend indoors vs. outdoors?Other than skin disease, does you pet have any diagnosed medical problems?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?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.Scratching/licking/biting at self Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeHair loss or poor regrowth of hair Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeIncreased redness to skin Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeSmall red spots, pimples, bumps, rash Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeDandruff, flakiness, scaliness of skin Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeIncreased odor of skin or coat Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeCrusty or scabby patches on skin Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeOpen, raw sores Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeAreas that ooze blood or pus Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeEyes—redness, irritation, itching, discharge Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeChange in color or texture of hair Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeDarkening of areas of the skin Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeEar infections Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeFleas seen on pet Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeDiarrhea or loose stools Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeVomiting Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeLoss of pigment of skin—black parts turn pink Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeSneezing or wheezing Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeChanges in pet’s usual personality Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeChanges in pet’s usual activity level Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeWeight loss or weight gain Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeChanges in pet’s appetite Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeChanges in amount of water consumed Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeChanges in urinary habits Never occurs or none Occurs rarely or slight Occurs occasionally or moderate Occurs often or severeHow much licking, biting, chewing, scratching, or rubbing does your pet do on the following areas of the body?Feet / Paws Not Itchy Mildly Itchy Moderately Itchy Severely ItchyLegs / Arms Not Itchy Mildly Itchy Moderately Itchy Severely ItchyAbdomen (belly)/genital area Not Itchy Mildly Itchy Moderately Itchy Severely ItchyArmpits/chest/sides of body Not Itchy Mildly Itchy Moderately Itchy Severely ItchyFace/eyes Not Itchy Mildly Itchy Moderately Itchy Severely ItchyEars/ear flaps Not Itchy Mildly Itchy Moderately Itchy Severely ItchyAlong the back or rump Not Itchy Mildly Itchy Moderately Itchy Severely ItchyThe tail itself Not Itchy Mildly Itchy Moderately Itchy Severely ItchyAnal area Not Itchy Mildly Itchy Moderately Itchy Severely ItchyIt 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.)Cortisone pills or shots (steroids, Temaril, prednisone, Vetalog, anti-itch pills)Was it ever given? Yes NoIf given, how much did it help? Did not help Helped some Helped a lotAntibiotics alone (with no other medication given at the same time)Was it ever given? Yes NoIf given, how much did it help? Did not help Helped some Helped a lotAntihistamine (Benadryl, Zyrtec, etc.)Was it ever given? Yes NoIf given, how much did it help? Did not help Helped some Helped a lotAntifungal medications (ketoconazole, etc.)Was it ever given? Yes NoIf given, how much did it help? Did not help Helped some Helped a lotCyclosporine (Atopica)Was it ever given? Yes NoIf given, how much did it help? Did not help Helped some Helped a lotApoquelWas it ever given? Yes NoIf given, how much did it help? Did not help Helped some Helped a lotAllergy shots or dropsWas it ever given? Yes NoIf given, how much did it help? Did not help Helped some Helped a lotPhoneThis field is for validation purposes and should be left unchanged.
