Medical History

Which location will you be visiting? *

Owner's First Name *

Owner's Last Name *

Owner Phone *

Owner email *

Owner address *

Primary Care Veterinarian *

Primary Veterinary Clinic *

Pet's Name *

Dog/Cat/Horse/Other *

Sex *

Breed *

Color *

Pet's Age *

Where did pet come from (e.g. breeder/shelter/stray) and age when adopted? *

Why are you bringing your pet to dermatology? *

When did problem(s) start? *

Is the problem seasonal or year-round *

Seasonal

Year-round

Are there times when problem is worse? Times when it is better? *

Does your pet lick/chew/scratch/rub and where? If yes, how would you rank the severity between 0 and 10 with 10 being the most severe itching that you could imagine? *

If yes, are there areas on your pet’s body that he/she focuses on? (front paws, hind paws, tail/back, arm pits, groin, ears, face) *

Does your pet have a history of ear infections? If yes, how frequently? *

List all medications, supplements and/or topical therapies that have been tried to your knowledge. (Please list the medications and refrain from "See Vet Record") *

What medications, supplements and/or topical therapies are you currently giving? (Please list the medications and refrain from "See Vet Record") *

Any therapeutics helped in the past? *

Is your pet on year-round flea and tick preventative? If yes, what kind and how often? *

Is your pet on heartworm preventative? If yes, what kind? *

Has your pet had recent lab work (within the past 3 months)? If yes, when and where? *

Approximate date (month/year) of last vaccinations: *

Are there other pets in the house? If yes, what kind and how many? *

Are any of the other pets experiencing similar issues? *

Yes

No

N/A

Are other pets in the house on year-round flea preventative? *

Yes

No

N/A

Are any of the people in the household experiencing similar issues? *

Yes

No

Any recent changes in your household that we should be aware of? (new pet, new house, new baby) *

Which of the following best characterizes where you live? *

What percentage of the time does your pet spend outdoors? *

Has your pet traveled anywhere outside of Oklahoma in the past 2 years? If yes, when and where? *

Does your pet have any behavioral issues that we should know about? *

How frequently do you bathe your pet? *

Do you clean your pet’s ears? *

Yes

No

If it were medically necessary, could you bathe your pet more frequently? If no, what do you perceive to be the barrier? (time, facilities, physical difficulties, pet temperament, cost) *

Do you have any difficulties medicating your pet? *

Yes

No

Has there been any change in: *

	None	Increase	Decrease
Activity Level	None	Increase	Decrease
Thirst	None	Increase	Decrease
Urination	None	Increase	Decrease
Appetite	None	Increase	Decrease
Weight	None	Increase	Decrease

Has there been any: *

	Yes	No
Coughing	Yes	No
Sneezing	Yes	No
Runny Eyes	Yes	No
Runny Nose	Yes	No
Limping	Yes	No

Is there a history of: *

	Yes	No
Vomiting	Yes	No
Diarrhea	Yes	No
Soft Stools	Yes	No
Belching	Yes	No
Flatulence	Yes	No

How many bowel movements in a day? *

What food(s) does your pet eat and for how long have they been on that food? *

Why did you choose that food? *

Does your pet eat people food? *

Yes

No

To the best of your recollection, what food(s) has your pet consumed in the past? *

Has your pet had a veterinarian diet trial (prescription grade food of at least 8 weeks duration)? *

Yes

No