Dermatologic History Questionnaire
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.