Lehigh Valley Veterinary Dermatology

4580 Crackersport Rd
Allentown, PA 18104

(610)391-1200

lehighvetderm.com

New Patient History Form

Name (required)
First Name (required)
Last Name (required)
Pet Name (required)

Best number to reach you on when here for the appointment (required)
Phone TypePhone Number (required)
E-Mail Address (required) :
Date of Appointment

Medical History
What skin/ear problems does your pet have? Check all that apply (required)
Itching (includes scratching, chewing, licking, rubbing, and biting)
Ear problems/infections
Skin rash
Skin infections
Hair loss
Dry skin/scaling/dandruff
What age was your pet when the problems began?

Which of the following best describes the progression of your pet's skin problem?
I first notice itching (such as scratching, biting, chewing, licking, or rubbing) prior to any skin lesions
I only notice itching (such as scratching, biting, chewing, licking, or rubbing) with no lesions
I notice a skin rash/lesions or hair loss followed by itching
I only notice skin rash/lesions or hair loss without any itching
None of the above apply to my pet
Rate itch level on a scale of 1 to 10 (1 = minimal, 10 = obsessive/constant)
1
2
3
4
5
6
7
8
9
10
Please check all of your pet's affected areas
Face
Ears
Feet
Neck
Tail
Groin
Arm pits
Legs
Feet/paws
Abdomen
Back
Sides
Nails
Nose/Muzzle
List the top three most affected areas on your pet's body and/or where your pet is the itchiest

Is the problem seasonal or year round?

Seasonal
Year round


If seasonal, in which season does the problem occur?
Winter
Spring
Summer
Fall
Not applicable
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
Fish
Horses
Cows
Chickens
Sheep
Goats
Guinea Pigs
Rabbits
Ferrets
Other Small Mammals (Mice/Rats/Hamsters/Gerbils)
Reptiles
Amphibians
Pet Bird (parrot, parakeet, cockatiel)
Can I count my children as pets since they don't clean up after themselves?
Can I count my spouse as a pet since he/she doesn't clean up after themself?
Do any of the other pets have skin problems/itching? 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 given

Has your pet ever been on a prescription diet or home cooked diet to rule out food allergies?

Yes
No


If you have done a food trial to rule out food allergy, which brand/diet did you use and for how long?

How many bowel movements does you pet have per day? Are there any other intestinal symptoms that your pet regulary has (soft stools, diarrhea, vomiting, flatulence)?

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


Do you live near farm land such as corn or hay fields? Please describe and indicate how close they are to your home.

Does your pet have any other signs of illness such as coughing/sneezing, vomiting, diarrhea, decreased appetite, excessive drinking or urination, limping, weight loss or weight gain?

Yes
No


If so, please describe

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

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

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

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

Topical treatments such as shampoos, sprays, creams, ointments, ear treatments? Please include names. Did they help?

Allergy shots or drops? Did they help?

Atopica (cyclosporine)? Did it help?

Apoquel? Did it help?

Cytopoint? Did it help?

Please list the current oral medications that your pet is receiving including milligrams and frequency of administration

Please list the current topical medications that you are using on your pet including topical ear treatments, shampoos, lotions, sprays etc and frequency of use.

Is there anything else you would like us to know about your pet and/or your pets skin/ear problems?

What is your primary care veterinarian's name and/or veterinary practice name?


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