Skin History Form 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? foul odor hair loss red skin red ears ear discharge scratching skin sores no response to previous treatmentIs this the first time your pet had a skin or ear problem?YesNoWhere 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 rapidIs the condition:IntermittentAlways presentAlways present, but waxes and wanesIs your pet itching?YesNoGrade from 1 (mild) to 10 (sever/constant):12345678910Does your pet lick its feet?YesNoIf yes to itching, check all that apply: biting scratching licking chewing gnawing rubbing scootingWhere: head/face mouth/muzzle ears neck chest belly back groin tail base thighs legs fet toes/nails armpit otherIf other, please describe:Is the itching:SeasonalYear RoundDon't KnowWhich season is it present: Spring Summer Fall WinterIn which season did it start: Spring Summer Fall WinterWhich seasons is it at its worst: Spring Summer Fall WinterWhat came first:Itching then lesions (rash, hair loss, red skin, etc.)Lesions then itchingDon't knowHow much time does your pet spend outdoors?Does your pet swim?YesNoHas your pet had an ear disease or had treatment with ear medications:YesNoWhen 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?YesNoIf 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 ExcellentHave 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 ExcellentHave 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 ExcellentHave 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 ExcellentHave 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 ExcellentHave 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 ExcellentHave 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 ExcellentHave 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 ExcellentHave 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 ExcellentHave 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 ExcellentHave 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 ExcellentHas your pet been allergy tested?YesNoIf 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?YesNoIs your pet on a flea prevention product?YesNoIf yes, name of product and frequency:Are there other pets in the household?YesNoAre any other animals in the household affected?YesNoAre any human family member affected?YesNoBriefly list other major health problems (i.e. Diabetes, Kidney Disease, Cushings):CAPTCHA
