Long Green Animal Dermatology
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HISTORY FORM
History Form - Fill Out Before First Visit
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Email
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Pet's Name
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Sex
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Breed
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Age
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Color
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Select One
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Spayed
Neutered
Intact
Chief Complaint(s)
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Age when problem first noted
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Onset
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Sudden
Slow
Seasonal Influence?
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Yes
No
If yes, which season?
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Winter
Spring
Summer
Fall
Not Applicable
Where on your pet did the problem begin?
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What did it look like then?
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Does your pet itch?
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Yes
No
When does your pet itch?
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Constant
Sporadic
Night
What areas of your pet's body are most affected?
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Where did you obtain your pet?
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Is there exposure to other animals?
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Yes
No
Do other animals or people in proximity have skin problems? If yes, describe
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Describe pet's indoor environment (i.e. carpet, tile, hardwood)
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Describe your pet's outdoor environment (i.e. grass, fenced yard, farm)
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Approximately what percent does your pet spend indoors vs outdoors?
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Where does your pet sleep?
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Groomed regularly? How often?
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What diagnostic tests has your regular vet performed?
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What topical treatments have been used?
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What oral treatments have been used?
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When did you last see fleas on your pet?
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What treatments have been successful?
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Currently using flea prevention?
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Yes
No
If yes to flea prevention, what brand?
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Is your pet on heartworm prevention?
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Yes
No
If yes to heartworm prevention, what brand?
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Briefly describe your pet's diet and how long they've been on that diet
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Does your pet have a history of vomiting, diarrhea, or soft stools?
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List all medications your pet is currently using
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Are there any other facts you think might be helpful?
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Submit
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