Patient History Form

Please answer the questions below and click submit.

Patient History Form

  • Owner Information

  • Patient Information

  • Patient's Dermatological History

  • 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/supplements
  • Pet food (include brand), treats, rawhides/bones, other (human food?)
  • 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, other