Microsoft word - c-\documents and settings\steven shaw.babh\my documents\derm history form 2009 (1).doc

Dr. Steven Shaw Dr. Jennifer Mills
Patient Dermatological History Form

Owner Name: ___________________________ Date: ______________
Pet’s Name: ____________________________ Pet’s Age: __________
Breed: _________________________________ Gender: ____________
One of the most important things you can do for your pet that has skin problems
is to provide us with detailed information on your pet’s problems.

1. What are your pet’s problems currently: (check all that apply)
Hair loss ( )
Scratching, chewing, licking, rubbing skin ( )
Red bumps, pimples, scabs ( )
Ear infections ( )
Skin infections ( )
Excessive dandruff, scaling ( )
Skin odor ( )
Nail infections or nail loss ( )
Other (describe) ( ) _____________________________________________
2. How long has/have the current problem(s) been present? ________________
3. What did your pet’s problems look like initially? ________________________
4. What areas of your pet are affected? (check all that apply)
Ears ( ); Face ( ); Neck ( ); Armpits ( ); Rump/tail area ( ); Underside ( );
Groin/inner thighs ( ); Legs/paws ( ); Anal/genital area ( ); Other ( ) _________
5. Has your pet’s skin problem changed? Yes ( ) No ( ).
If yes, please describe: __________________________________________
If yes, what areas are affected now? ________________________________
_____________________________________________________________
6. What treatment has your pet received for his/her skin problem?
Check all that apply and list or circle names if possible:
( ) Antibiotics (list) ______________________________________________
( ) Oral cortisone e.g.: prednisone, Vetalog, Dexamethasone
( ) Cortisone/steroid injections
( ) Antihistamines e.g.: Benadryl, Atarax, chlorpheniramine
( ) Fatty acids/oils, fish oil capsules, Derm caps, vegetable oils
( ) Ivermectin (anti-mite injections)
( ) Ear ointments or drops (please list) _______________________________ ( ) Herbal or homeopathic remedies (please list) _______________________ 7. Did medication/therapy help your pet’s problem(s)? Yes ( ) No ( ) If no, go to 8. If Yes, which medication was the most effective? _____________________________________________________________ Did the lesions resolve with this medication/therapy? Yes ( ) No ( ) Did the lesions return after the medication/therapy was stopped? Yes ( ) No ( ) How long did it take for the lesions to return? ____________ (weeks/months) circle 8. On a scale of 1-10 with 1= occasional chewing or scratching and 10= severe constant scratching that keeps you up at night, how would you rate your pet’s level of itchiness now? (circle number from 0-10): 0 1 2 3 4 5 6 7 8 9 10 How would you rate chewing or scratching while your pet was on antibiotics? ________ (1 – 10) Not given antibiotics ( ). How would you rate chewing or scratching while your pet was on antihistamines? __________ (1 – 10) Not given antihistamines ( ) How would you rate chewing or scratching while your pet was on steroids? _________ (1 – 10) Not given steroids ( ). 9. Is/are your pet’s problem(s) intermittent ( ) or continual ( )? 10. Is there currently a relationship between your pet’s problem(s) and the season of the year? Yes ( ) No ( ) If yes, please check the season(s) when the problem is worse: Spring ( ); Summer ( ); Fall ( ); Winter ( ) The problem begins in _______ (month) In the past was there a relationship between your pet’s problem(s) and the season of the year? Yes ( ) No ( ) If yes, what seasons?_______________ 11. Do you have any other pets? Yes ( ); No ( ); Please list any other pets_________________________________________________________ 12. Do your other pets have similar skin conditions? Yes ( ); No ( ); Does not apply ( ). If yes, what are the other pet’s problems? __________________ ____________________________________________________________ 13. Describe the indoor environment of your pet – such as bedding, where he/she sleeps, etc. _____________________________________________ 14. Describe the outdoor environment (grasses, weeds, trees, wooded areas, etc) _________________________________________________________ How many hours of the day is your pet outdoors? _____________________ 15. Have you noticed fleas on your pet recently? Yes ( ); No ( ) 16. What flea products do you currently use? ___________________________ Flea products not used ( ). 17. Has any person in your household had skin problems since your pet started having skin problems? Yes ( ); No ( ) If yes, please describe ____________________________________________________________ 18. What oral or injectable medication is your pet presently receiving and when was it last given? ______________________________________________ 19. Are any medications currently being used topically on your pet (include ear medications)? Which one(s)? ______________________ Applied where? ____________________________________________________________ 20. Which food is your pet currently receiving? _________________________ How long? _________________________ 21. Does your pet receive anything else to eat? E.g. table food, treats, biscuits, vitamin supplements, or rawhide chews given? Please list: _____________________________________________________________ 22. Does your pet have any other previously diagnosed medical or surgical problems unrelated to the skin disorder? Yes ( ); No ( ) Please describe: _____________________________________________________________ _____________________________________________________________ Is your pet receiving any medication for this disorder? Please list medications: __________________________________________________ _____________________________________________________________ 23. Have you noticed any change in the health or behavior of your pet that coincided with the development of the skin condition? (e.g. changes in food or water intake, changes in urination or defecation, changes in activity level) Yes ( ) No ( ) Please list: _______________________________________ _____________________________________________________________ 24. Has your pet ever been on a special food elimination diet? Yes ( ); No ( );
If yes, what commercial brand of food or home-cooked diet ingredients were
used and for how long? _________________________________________
_____________________________________________________________
Were treats, table food, biscuits, rawhides, or chewable medications given
while on the diet? Yes ( ); No ( )
25. For Dogs: Is your pet currently on heartworm preventative (Heartgard,
Interceptor, Filaribits)? Yes ( ); No ( ) If yes, is it a chewable?
Yes ( ); No ( )
26. For Cats: Was your pet tested for feline leukemia virus (FeLV)?
Yes ( ); No ( )
27. Has you pet always lived in this part of the country? Yes ( ); No ( )
If no, where did you live before and when did you move?
_____________________________________________________________
_____________________________________________________________
Thank you for completing the questionnaire. Please give to one of the
receptionists when you arrive for your appointment.

Source: http://www.broadviewpetmedicalcenter.com/derm%20history.pdf