Skin History Form in Hopedale, OH | Heritage Veterinary Care

Date

Date Format: MM slash DD slash YYYY

Pets Name:

Owner's Name

First Last

Email*

What are your primary concerns?

What changes do you see as a problem?

Is this the first time your pet had a skin or ear problem?

Yes
No

Where on the body did the problem first appear?

When did the disease first start?

How has the disease progressed?

Slow (months to years)
Rapid (days to weeks)
Slow at first then more rapid

Is the condition:

Intermittent
Always present
Always present, but waxes and wanes

Is your pet itching?

Yes
No

Grade from 1 (mild) to 10 (sever/constant):

Does your pet lick its feet?

Yes
No

If yes to itching, check all that apply:

Where:

If other, please describe:

Is the itching:

Seasonal
Year Round
Don't Know

Which season is it present:

Spring
Summer
Fall
Winter

In which season did it start:

Spring
Summer
Fall
Winter

Which seasons is it at its worst:

Spring
Summer
Fall
Winter

What came first:

Itching then lesions (rash, hair loss, red skin, etc.)
Lesions then itching
Don't know

How much time does your pet spend outdoors?

Does your pet swim?

Yes
No

Has your pet had an ear disease or had treatment with ear medications:

Yes
No

When was the last ear disease or ear treatment?

Commercial food:

Table food/scraps:

Treats:

Supplements:

Flavored/chewable medications (e.g. Heartworm preventatives, arthritis medications, etc):

Previous Diets:

Has your pet been on a food trial?

Yes
No

If yes, duration of trial and food used?

Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent

Has your pet been allergy tested?

Yes
No

If yes, when and where was it blood or skin testing?

Current treatments for skin or ear disease:

When was the last time your pet had topical medication applied?

How often is your pet bathed?

Shampoo brand:

Have you changed shampoo or topical treatment recently?

Yes
No

Is your pet on a flea prevention product?

Yes
No

If yes, name of product and frequency:

Are there other pets in the household?

Yes
No

Are any other animals in the household affected?

Yes
No

Are any human family member affected?

Yes
No

Briefly list other major health problems (i.e. Diabetes, Kidney Disease, Cushings):

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