Dermatology History Form

Your First and Last Name*
Pets name?*
What is the primary complaint with the skin?
Are the ears involved?*
- Yes
- No
If yes, explain.
When did the problem start?
What was the skin like initially? (Check all that apply)*
If other, explain
Where did the problem start?*
- Nose
- Eyes
- Ears
- Neck
- Back
- Paws
- Front Legs
- Back Legs
- Rump
- Chest
- Stomach
- Other
If other, explain.
Has the problem spread?
If yes, where?
Is your pet itching? Itch = scratch, rub, chew, lick, bite, etc*
- Yes
- No
If so, where on the below scale would you put your pet's itch level?*
If itchy, was it from onset of the problem or is it a new occurance?
Is the skin problem worse or more severe at a certain time of the year, or is it the same throughout the year?*
If worse at a certain time of year, what time of year is it worse?
Do you have any other pets?
If yes, please list.
Do your other pets have skin problems?
Diet Information
If yes, please describe.
Do any people in your house have a skin condition or problem?*
What do you feed your pet?*
What type of supplements/vitamins do you give your pet?*
What type of snacks or treats does your pet get (include human food)?*
Medication Information
What medications/supplements is your pet currently on?*
Has your pet ever had a reaction to medication?*
If your pet has been given any medication for skin conditions, which (if any) have helped?*
Is your pet on flea control*
If yes, what type?
Is your pet on heartworm prevention?*
If yes, what type?
How often do you bathe your pet?*
What shampoo do you use?*
Environmental
What percentage of the day does your pet spend indoors?*
Outdoors?*
Please describe the outdoor environment*
Other Medical Problems
Does your pet have any other illness?*
If yes, which ones?
Does your pet do any of the following excessively (check all that apply):
How many bowel movements does your pet have per day?*

Contact.

977 Farmington Ave
Kensington, CT 06037

Phone: (860) 828-7736

Fax: (860) 829-0594

Hours.

Monday – Friday
8:00am – 5:00pm

Saturday
8:00am – 12:00pm

Sunday
Closed

Dermatology History Form

Diet Information

Medication Information

Contact.

Hours.