HISTORY FORM

History Form - Fill Out Before First Visit

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Pet's Name *

Sex *

Breed *

Age *

Color *

Select One *

Chief Complaint(s) *

Age when problem first noted *

Onset *

Seasonal Influence? *

If yes, which season? *

Where on your pet did the problem begin? *

What did it look like then? *

Does your pet itch? *

When does your pet itch? *

What areas of your pet's body are most affected? *

Where did you obtain your pet? *

Is there exposure to other animals? *

Do other animals or people in proximity have skin problems? If yes, describe *

Describe pet's indoor environment (i.e. carpet, tile, hardwood) *

Describe your pet's outdoor environment (i.e. grass, fenced yard, farm) *

Approximately what percent does your pet spend indoors vs outdoors? *

Where does your pet sleep? *

Groomed regularly? How often? *

What diagnostic tests has your regular vet performed? *

What topical treatments have been used? *

What oral treatments have been used? *

When did you last see fleas on your pet? *

What treatments have been successful? *

Currently using flea prevention? *

If yes to flea prevention, what brand? *

Is your pet on heartworm prevention? *

If yes to heartworm prevention, what brand? *

Briefly describe your pet's diet and how long they've been on that diet *

Does your pet have a history of vomiting, diarrhea, or soft stools? *

List all medications your pet is currently using *

Are there any other facts you think might be helpful? *

Submit