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Garden State Veterinary Specialists Dermatology History Form

Please submit this form no less than 48 hours before your appointment. Thank You.

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)

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