Lehigh Valley Veterinary Dermatology

4580 Crackersport Rd
Allentown, PA 18104

(610)391-1200

lehighvetderm.com

Patient History Form

Name
First Name
Last Name
Pet Name

Phone
Phone TypePhone Number
Date of Appointment

What is your pet's main problem? Check all that apply
Itching (includes scratching, chewing, licking, rubbing, and biting)
Ear problems
Skin rash
Skin infections
Hair loss
Dry skin, scaling, dandruff
Other, please describe

What age was your pet when the problems began?

Rate itch level on a scale of 1 to 10 (1 = minimal, 10 = obsessive) :
Please check all of your pet's affected areas
Face
Ears
Neck
Tail
Groin
Arm pits
Legs
Feet/paws
Abdomen
Back
Sides
Nails
Nose
In which location did the problem begin?

Is the problem seasonal or year round?
seasonal
year round


If seasonal, in which season does the problem occur?
winter
spring
summer
fall


If year round, do the signs worsen during a particular season?
winter
spring
summer
fall
no


Do you have any other pets? Check all that apply
Dogs
Cats
Birds
Other (fish, horses, reptiles, hamster, etc)

Do any of the other pets have skin problems? If so, please describe

Do any people in the home have skin lesions? If yes, please describe

Diet Questions
What is your pet's current diet, include treats

Has your pet ever been on a prescription diet to rule out food allergies?
yes
no


Environmental Questions
What percentage of time does your pet spend indoors vs. outdoors?

What is the primary indoor flooring surface? :
Do you have wool carpeting?
yes
no


Does anyone in the household smoke?
yes
no


Does your pet have any other signs of illness?
yes
no


If so, describe

What is your pet's flea/tick prevention? How often is it applied?

Treatment: Has your pet received the following medications?
Antihistamines (Benadryl, Hydroxyzine, Zyrtec, other)? Did they help?

Steroids (Prednisone, Temaril P, Steroid/cortisone shots)? Did they help?

Antibiotics (Cephalexin, Simplicef, Clavamox, Baytril, Zeniquin)? Did they help?

Shampoos/conditioners? Did they help?

Allergy shots? Did they help?

Atopica (cyclosporine)? Did it help?

Please list the current medications that your pet is receiving


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