Owner's Name Pet's Name

Date of Appointment (M/D/Y)

1. What is the skin problem?
   

   Itching	Hair Loss	Rash	Redness	Sores
   Oily Skin	Dry Skin	Dandruff	Odor	Other

2. At what age did you first notice the problem?
3. Is the problem year round? Yes No Unknown
4. Is the problem worse at any particular time of the year?
   Spring Summer Fall Winter
5. What did the problem look like when it first started?
   Itching Hair Loss Rash Redness Other
6. Where did it start?
   

   Nose	Eyes	Ears	Neck	Back	Rump
   Tail	Legs	Paws	Chest	Stomach	Groin

7. Has it spread? Yes No
   If yes, where?
8. Does your pet scratch, rub, chew, lick, or bite? Yes No
9. Where does your pet itch?
   

   Nose	Eyes	Ears	Neck	Back	Rump
   Tail	Legs	Paws	Chest	Stomach	Groin

10. Was itching the first thing you noticed? Yes No
    If no, what was?
11. What is the intensity of the itching?
    Mild Moderate Severe Constant
12. How long have you had your pet?
13. Do you have other pets? Yes No
    If yes, what kind?
14. Do any have skin problems? Yes No
    If yes, what kind?
15. Do any people in the household have skin problems? Yes No
    If yes, what kind?
16. Percent of time your pet is: % Indoors % Outdoors
17. Describe your pet’s indoor environment (bedding, rugs, sleeping location, etc.)
    
18. Describe your pet’s outdoor environment (yard, vegetation, pen, garage, etc.)
    
19. Has your pet been out of his/her normal area (vacation, visit, boarded, etc.)?
    Yes No
    Where: When:
20. Does your pet go to a groomer? Yes No
    If yes, how often?
21. Does your pet have fleas? Yes No Did have
22. Are there any other parasite problems? Ticks Flies Mites
23. What products do you use for flea control?
    
24. What medications have been used (shots, pills, ointments, drops, etc.) for the skin problem? Medication Name, How Much, How Often, Did it help?
    
25. What shampoos and rinses have been used?
    
26. What type and brand of food do you feed your pet?
    Canned Dry Table Food Other
27. Does your pet have any of the following?
    

    Cough	Sneeze	Runny Nose	Runny Eyes
    Vomiting	Diarrhea	Poor Appetite	Excessive Appetite
    Increased Water Intake	Change in Urination Habits	Change in Activity Level

28. Has your pet had any drug reactions or other illnesses?
    
29. Other current medication (include heartworm, supplements, vitamins)