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Patient history form

Dr. Kevin Byrne, DVM, MS
Diplomate American College of Veterinary Dermatology
Patient History Form
List any drug allergies: ____________________ This information will help us help your pet. 1. What are your pet’s problems currently: (check all that apply) Scratching, chewing, licking, rubbing, skin ( ) Red bumps, pimples, scabs ( )Ear infections ( ) Nail infections or nail loss ( )Other (describe) ( ) ___________________________________________ 2. How long has/have the current problem(s) been present? _____________ 3. What did your pet’s problems look like initially? ______________________ 4. What areas of your pet are affected? (check all that apply) Ears ( ); Face ( ); Neck ( ); Armpits ( ); Rump/tail area ( ); Underside ( ); Groin/inner thighs ( ); Legs/paws ( ); Anal/genital area ( ); Other___________ 5. What treatment has your pet received for his/her skin problem? Check all that apply and list or circle names if possible: Antibiotics (list if you know) __________________________________ Oral cortisone e.g.: prednisone, Vetalog, dexamethasone Antihistamines e.g.: Benadryl, Atarax, chlorpheniramine Fatty acids/oils, fish oil capsules, vegetable oils Ear ointments or drops (list if you know) _______________________ Herbal or homeopathic remedies (list if you know) ______________ Allergy vaccines: based on skin test: __ or blood test: __ 6. Did medication/therapy help your pet’s problem(s)? Yes( ) No( ) If no, go to 7If yes, which medication was the most effective?_____________________________ Did the lesions resolve with this medication/therapy? Yes( ) No( ) Did the lesions return after medication/therapy was stopped? Yes( ) No( ) How long did it take for the lesions to return?___________ (weeks/months)(circle) 7. On a scale of 1-10 with 1 = occasional chewing or scratching and 10 = severe, constant scratching that keeps you up at night, how would you rate your pet’s level of itchiness now? (circle number from 0-10): 0 1 2 3 4 5 6 How would you rate chewing or scratching while your pet was on antibioticsand nothing else?____/10. Or, my pet was never on antibiotics alone: __ 8. Is there currently a relationship between your pet’s problem(s) and the season of the year? Yes ( ) No ( ) If yes, please check the season(s) when the problem is worse: Spring ( ); Summer ( ); Fall ( ); Winter ( ) In the past was there a relationship between your your pet’s problem(s) and the season of the year? Yes ( ) No ( ) If yes, what seasons? ____________________ 9. Do you have any other pets? Yes ( ); No ( ); Please list any other pets ______ 10. Do your other pets have any skin problems? Yes ( ); No ( ); Does not apply ( ) If yes, what are the other pet’s problems? __________________________ 11. Describe the indoor environment of your pet – such as bedding, where he/she sleeps, etc. _______________________________________________________ 12. Describe the outdoor environment (grasses, weeds, trees, wooded areas, etc…) __________________________________________________________________How many hours of the day is your pet outdoors?__________________________ 13. Have you noticed fleas on your pet recently? Yes ( ); No ( ) 14. What flea products do you currently use? _____________________________ 15. Has any person in your household had skin problems since your pet started having skin problems? Yes ( ); No ( ) If yes, please describe _________________ 16. What oral or injectable medication is your pet presently receiving and whenwas it last given? _____________________________________________________ 17. What shampoos, sprays, creams, ointments, lotions are your pet presently receiving? __________________________________________________________ What ear medications and cleansers is your pet presently receiving?_____________________________________________________________________ 18. Which food is your pet currently receiving? ______________How long? _____ 19. Does your pet receive anything else to eat? E.g. table food, treats, biscuits, vitamin supplements, or rawhide chews given? Please list ____________________ _______________________________________________________________________ 20. Does your pet have any other medical or surgical problems unrelated to the skin disorder? Yes ( ); No ( ) Please describe: ______________________________________________________________________ Is your pet receiving any medication for this disorder? Please list medications: ______________________________________________________________________ 21. Are there any changes in food or water intake, changes in urination ordefecation, changes in activity level?Yes ( ) No ( ) Please list: ________________________________________________ 22. Has your pet ever been on a special food elimination diet? Yes ( ); No ( ); If yes, what brand of food or home-cooked diet ingredients were used and for howlong? _______________________________________________________ Were treats, table food, biscuits, rawhides, or chewable medications given 23. For dogs: Is your pet currently on heartworm prevention? Yes ( ); No ( ) If 24. For cats: Was your pet tested for feline leukemia virus (FeLV)? Yes( ) No( ) 25. Has your pet always lived in this part of the country? Yes ( ) No ( )

Source: http://www.allergyearskincare.com/animal-care/images/PDF/patient-history-form.pdf

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