Dermatology History Form Name*Date* Date Format: 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 medicationContinual but better with medicationIntermittent 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 selfNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeHair loss or poor regrowth of hairNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeIncreased redness to skinNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeSmall red spots, pimples, bumps, rashNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeDandruff, flakiness, scaliness of skinNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeIncreased odor of skin or coatNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeCrusty or scabby patches on skinNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeOpen, raw soresNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeAreas that ooze blood or pusNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeEyes—redness, irritation, itching, dischargeNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeChange in color or texture of hairNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeDarkening of areas of the skinNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeEar infectionsNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeFleas seen on petNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeDiarrhea or loose stoolsNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeVomitingNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeLoss of pigment of skin—black parts turn pinkNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeSneezing or wheezingNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeChanges in pet’s usual personalityNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeChanges in pet’s usual activity levelNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeWeight loss or weight gainNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeChanges in pet’s appetiteNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeChanges in amount of water consumedNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeChanges in urinary habitsNever occurs or noneOccurs rarely or slightOccurs occasionally or moderateOccurs often or severeHow much licking, biting, chewing, scratching, or rubbing does your pet do on the following areas of the body?Feet / PawsNot ItchyMildly ItchyModerately ItchySeverely ItchyLegs / ArmsNot ItchyMildly ItchyModerately ItchySeverely ItchyAbdomen (belly)/genital areaNot ItchyMildly ItchyModerately ItchySeverely ItchyArmpits/chest/sides of bodyNot ItchyMildly ItchyModerately ItchySeverely ItchyFace/eyesNot ItchyMildly ItchyModerately ItchySeverely ItchyEars/ear flapsNot ItchyMildly ItchyModerately ItchySeverely ItchyAlong the back or rumpNot ItchyMildly ItchyModerately ItchySeverely ItchyThe tail itselfNot ItchyMildly ItchyModerately ItchySeverely ItchyAnal areaNot ItchyMildly ItchyModerately ItchySeverely 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?YesNoIf given, how much did it help?Did not helpHelped someHelped a lotAntibiotics alone (with no other medication given at the same time)Was it ever given?YesNoIf given, how much did it help?Did not helpHelped someHelped a lotAntihistamine (Benadryl, Zyrtec, etc.)Was it ever given?YesNoIf given, how much did it help?Did not helpHelped someHelped a lotAntifungal medications (ketoconazole, etc.)Was it ever given?YesNoIf given, how much did it help?Did not helpHelped someHelped a lotCyclosporine (Atopica)Was it ever given?YesNoIf given, how much did it help?Did not helpHelped someHelped a lotApoquelWas it ever given?YesNoIf given, how much did it help?Did not helpHelped someHelped a lotAllergy shots or dropsWas it ever given?YesNoIf given, how much did it help?Did not helpHelped someHelped a lotPhoneThis field is for validation purposes and should be left unchanged.
