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Patient History Form
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Client Name:
*
Your answer
Patient Name:
*
Your answer
Breed:
*
Your answer
Age:
*
Your answer
Sex:
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Male
Female
Chief Complaint (why are you here):
*
Your answer
Please check any that describe your pet
Hair loss
Foul odor
Inflammation or redness
Itching/scratching/rubbing
Licking/chewing
Skin lesions (sores)
Skin changes (staining, discoloration)
Ear problems
Gastrointestinal signs (diarrhea, vomiting)
Other:
Rank the severity or your pet’s condition overall (1= nonexistent, 10= severe)
nonexistent
1
2
3
4
5
6
7
8
9
10
severe
Clear selection
Rank the severity scratching/licking/chewing (1= nonexistent, 10= severe)
nonexistent
1
2
3
4
5
6
7
8
9
10
severe
Clear selection
Is this the first time that your pet has experienced these symptoms?
*
Yes
No
If no, then at what age did the symptoms first occur?
Your answer
If no, has it occurred around the same time each year?
Yes
No
Clear selection
If no, approximate time of year symptoms occur
Spring
Summer
Fall
Winter
How long have the current symptoms been going on?
Your answer
Did the itch start gradually and over time become worse?
Your answer
Was there a “rash” or itching first? Or simultaneous?
Your answer
Where on the body did the problem begin?
Your answer
What did it look like then?
Your answer
Is there any exposure to other animals (yours, neighbors, etc)?
Your answer
Do other animals or people in the household have skin problems, rash?
Your answer
How much time does the pet spends indoor vs. outdoor?
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All of the time indoors
1
2
3
4
5
6
7
8
9
10
All of the time outdoors
Where does the pet sleep?
Your answer
What diagnostic tests have been performed?
Your answer
Indicate previous treatments administered to your pet
Cortisone/Steroids
Shampoos
Sprays
Ointments
Antibiotics
Foods
Fatty acids
Antihistamines
Immunotherapy
Other:
Describe your flea control, frequency of treatment, and last time fleas seen
Your answer
What pet food are you feeding?
Your answer
Do you feed the same food all the time or provide a variety?
Your answer
Have you changed the diet recently?
Yes
No
Clear selection
Do you give your pet packaged treats or “human food”?
Yes
No
Clear selection
Medical history: previous diseases, treatments, results
Your answer
Is the animal on any medications at present?
Yes
No
Clear selection
If yes, which ones?
Your answer
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