Skin History Form Date 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? foul odor hair loss red skin red ears ear discharge scratching skin sores no response to previous treatment 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): 1 2 3 4 5 6 7 8 9 10 Does your pet lick its feet? Yes No If yes to itching, check all that apply: biting scratching licking chewing gnawing rubbing scooting Where: head/face mouth/muzzle ears neck chest belly back groin tail base thighs legs fet toes/nails armpit other 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 Steroids/cortisone/depo medrol (shots, pills) No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Antibiotics (shots, pills) No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Antifungals No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Ear medications No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Topical skin medications No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Atopica No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Apoquel No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Fatty acid supplements No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Antishistamines No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Cytopoint No response Poor Good Excellent Have you used any of the following medications for your pet? If yes, rate their response when on medication from poor to excellent Allergy Shots (immunotherapy) No response Poor Good 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):CAPTCHA
