Dermatology History
Owners first & last name: *
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Patients name: *
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Appointment date: *
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Briefly state the problem *
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When was the problem first noted? *
Month & year, please
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Is the problem year round? *
Are the problems more severe during particular season(s)?
Is there scratching, chewing, licking or rubbing? *
The scratching, chewing, licking and rubbing is:
Where does your pet itch, chew, lick or rub? *
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Where on the body did the problem begin? *
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Are fleas currently present on any of your pets?
What brand of flea/tick preventative do you use & when was the last dose given?
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Do other pets that have contact with the patient have skin problems?
Do littermates or the parents of the pet have skin problems?
How often do you bathe your pet & with what shampoo?
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How often do you clean your pets ears & with what cleanser?
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Which medications have been used to treat the skin issues in the past? *
Drug, amount, frequency & did it help?
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Which drug(s) have helped the most?
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Anything else that you think may be helpful?
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