Patient History Form Please answer the questions below and click submit. Patient History Form Owner InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number*Patient InformationName*Sex*Species*Breed*Age*Patient's Dermatological History1. How old was your pet when you first observed signs of skin (and/or ear) issues?*2. How long has the skin (and/or ear) issue been present?*3. Do these skin (and/or ear) issues occur:* A. Seasonally* B. Year round C. Year round with seasonal worsening* * If seasonal, which seasons are the worst?4. Is your pet itchy? If so, how itchy is your pet on a scale of 1-10 (with 1 indicating a normal dog and 10 indicating constant, severe itch):*5. If lesions are present, where did the lesions first start and what did they first look like?*6. What diagnostic tests have been performed so far? Please include intradermal skin tests, serology, skin biopsies/cytology, food trials, blood work, etc:*7. What were the results of the diagnostic tests? Please provide copies of blood work, histopathology, etc. if available:*8. What medications (drug name, dosage, duration) have been used previously for skin issues and what was the response to each medication given?*9. What medications is your pet currently taking? Please indicate the drug name and dose you are giving, how many times per day and for how many days you have been giving each medication:*Examples: antibiotics (i.e. cephalexin), antifungals (i.e. ketoconazole), antihistamines (i.e. benadryl), fatty acids, steroids (i.e. prednisone), topical medications/creams/ointments/sprays, flea/tick/heartworm medications (i.e. chewed or flavored?), shampoos/conditioners, other/supplements10. What is your pet's current diet?*Pet food (include brand), treats, rawhides/bones, other (human food?) 11. When was your pet last tested for heartworms?*12. Does your pet receive baths regularly? If so, how often? Does your pet go swimming?*13. Do you clean your pet's ears regularly? If so, what do you use to clean them?*14. Has your pet ever had an adverse reaction to an ear cleaner? If so, which cleaner and what did you observe?*15. Please list all other animals in the home. Does your pet come in to contact with other animals outside the home (neighborhood or other homes)? Do any of the other pets have signs of skin disease?*16. How long has your pet lived in Florida? Has your pet recently traveled?*17. Is your pet showing any other signs of illness?*Examples: weight loss, weight gain, drinking more water/urinating more frequently, vomiting, diarrhea, weakness/low energy level, excessive hunger relative to normal for your pet, other18. When was your pet last vaccinated? What was your pet vaccinated for?*19. Please describe your pet's home environment, check off all that apply:* A. My pet lives indoors all the time. B. My pet lives both indoors and outdoors. C. My pet lives outdoors all the time. D. I have a fenced/enclosed yard. E. My yard is continuous with wilderness. F. I do not have a yard. G. I have wall to wall carpets inside. H. The floors inside the house are hard surfaces. I. I have a combination of carpet and hard surfaces.