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Canine dermatology history form
Please fill out and submit this form before your scheduled appointment time.
BE SURE TO BRING THE PREVIOUS MEDICATIONS, PILLS, OINTMENTS, EAR CLEANERS, SHAMPOOS, EVEN IF EMPTY TO THE CONSULTATION. BRING FOOD AND TREAT INGREDIENT LABELS.
DO NOT BATHE YOUR DOG WITHIN 5 DAYS, DO NOT CLEAN OR TREAT EARS WITHIN 2 DAYS OF YOUR DOG'S APPOINTMENT.
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Indicates required field
Your Name
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Pets Name
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Pets Age
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Less than 1yr
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2
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Pets Breed
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Sex
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Spayed Female
Intact Female
Neutered Male
Intact Male
Primary Concerns about your dogs skin.
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When was this first noticed?
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Was this onset rapid or gradual?
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Rapid
Gradual
Has always been there.
Does the pet itch?
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Yes, all the time
Yes, sometimes
Yes, only at night
No
Rate your pets itch (10-constant severe itching all day and night, 0-no itching)
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0
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10
What time of year is your pet most itchy?
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Winter
Spring
Summer
Fall
Where does your dog spend time?
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Only goes outside to potty ~30 minutes a day
Goes outside for awhile multiple times a day when weather is appropriate
Spends almost all day outside
Outdoor only pet.
Are there other pets in the home, if so how many?
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No other pets
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Do any people in the house have skin problems or itching?
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If yes, do these pets have skin problems or itching?
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What is the name of your dog's food?
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What treats or table food does your dog eat?
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What flea control do you use and how often? year round?
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If there are other pets in the home do they get flea control at the same intervals?
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How often do you bathe your pet?
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What medication is your pet taking at this time?
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What previously prescribed medications have helped your pet?
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What other health problems does your dog have?
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Please share any additional information that you think is important for us to know:
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How often does your dog swim?
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Submit
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COVID-19 Practice Changes