Dermatologic History Questionnaire

Owners Name:

Pet's Name:



Sex: M  F

Spayed or Neutered?  Yes No

Please describe the main problem with your pet's skin, ear, nails?


Where did you get your pet?  Shelter  Pet Store Breeder  Other: 

At what age did you first notice problems?  How quickly did the problems start?  Suddenly  Gradually

Does your pet itch or lick excessively or over groom(cats)?  Yes  No

If yes, how often?  Constantly  Off and on throughout the day  When left alone  During the night

Rate itching from 1-10 (1 only occasionally; 10 constant day and night) 

When is the problem the worst?  Spring  Summer  Fall  Winter  All year round  I don't know

Where on your pet's body did the problem first begin?


What did it look like at first?


What other pets are in the household?


Do the other pets or people in the household have itching, skin problems, rash?


Where does your pet spend most of their time? Indoors  % Outdoors  %

Does your pet swim?  Yes No        How often? 

Do you or your groomer bathe your pet?  Yes  No 

If yes, how often and what products are used?


What shampoos, sprays, creams or ear medication and cleaners have you used? Which worked best?


What pills or injections have you tried? Which worked best?


When was the last time fleas where seen on any of your pets? 

            What products do you use? 

            Which pets were treated? 

            Are all the pets in your household treated at the same time? 

            Do you use preventative all year round or seasonally? 

Describe your pet's diet. (Include food brand(s), snacks, and treats.)


Does your pet have any other medical problems?


Has there been any change in your pet's behavior since the skin or ear problems started? (ex. change in energy, body weight, drinking, urinating, change in bowel movements)


What do YOU think is causing your pet's skin problems?


Note: Please bring all pills, ear drops, creams, ear cleaners, shampoos, sprays and any other products to the appointment- even if they are empty. Please DO NOT bathe your pet within 5 days of the appointment or clean your pet’s ears within 3 days of the appointment.

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Our Funkstown veterinarians offer a wide variety of pet care services including spay and neutering, general exams, vaccinations, and much more. Contact Animal Health Clinic of Funkstown today to schedule an appointment at our Funkstown, Maryland veterinary office.

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