Initial History Form

Please help us get to know your pet before their first dermatology appointment. By completing this form ahead of time, you allow our team to prepare for your consultation and provide personalized, effective care from the start.

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Tell Us About Your Pet’s History

Before your visit, please fill out the following questionnaire. Your answers give our veterinary dermatology team valuable insights into your pet’s medical background and current concerns. This allows us to make the most of your appointment time and build a customized treatment plan.

Initial History Form

Name *

First

Last

Email *

Phone

Pet's Name *

Where did you obtain your pet?

What are the current skin/ear concerns you have for your pet?

Rate your pet's level of itch on a scale from 0 to 10. (0 is normal, and 10 is the worst an animal can be)

We consider licking, biting, chewing, rubbing, and scratching to be an itch.

Where on your pet's body are they uncomfortable?

How old was your pet when this first started?

Are there certain times of the year that your pet appears to be worse than others?

Are there any times of the year that your pet's skin/ears are completely normal?

Signature Does Has

Has the condition responded to any treatment that you have tried so far? If so, which treatment has worked best?

Does your pet have any other major medical concerns?

Has your pet had any bloodwork done recently?

What medications is your pet taking currently?

This would also include vitamins, supplements, and any topical therapy such as ear cleaner or shampoo.

Is your pet current on all vaccinations?

Do you use heartworm prevention?

Do you use any flea and tick prevention?

Does your pet spend most of the time indoors, or do they live strictly outdoors?

Do you have any other pets in the house?

Do any other pets in the house have any skin concerns?

Do any humans in the house have any skin issues?

Does your pet travel anywhere out of state?

Does your pet go to dog parks, daycare, boarding facilities, or a groomer?

Has your pet had any recent vomiting or diarrhea?

Has your pet had any recent coughing or sneezing?

Have you noticed any increase or decrease in urination?

Have you noticed any increase or decrease in appetite or water intake?

How has your pet's attitude and activity been recently?

What diet are you currently feeding your pet?

Please list any diets you have previously fed your pet:

Please provide the best phone number to contact you at: *

Signature *

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Today's Date *

Initial History Form

Tell Us About Your Pet’s History

Initial History Form

We’re Ready to Help Your Pet Feel Better

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