Forms

Dermatology History Form

If this is an emergency case, please do not fill out form and directly call our practice to speak with reception.

Client name

Client Phone

Pet Name

How long have you owned your pet?

Pet's date of birth

Has your pet lived outside of Alaska?

Yes No

If so, where and when?

How long has your pet had skin or ear problems?

Is the problem present year-round or worse at a particular time of year?

Year-round Spring Summer Fall Winter Select all that apply

At what time of the year did the problem start?

What was the initial problem?

Itchy Skin Rash/Redness Hair Loss Ear Infections Other Check all that apply

Has problem spread or worsened?

Yes No

Where has it spread?

Do you have other pets or farm animals? Please list if applicable.

If you have other pets, do they have skin problems?

(explain briefly)

Do any people in the house have skin problems?

Yes No

Amount of time pet spends indoors

(in percentage %)

Amount of time pet spends outdoors

(in percentage %)

Is there a time of day when the symptoms seems worse or are they worse indoors or outside?

Please list any medications your pet has had for skin or ear problems, please also explain the ones you feel have helped

Please list your pet’s primary diet and any treats, chews or vitamins they receive.

(Please provide both the brand name and primary protein)

Please list your pet’s previous diet and when they were switched to a new diet.

(Please provide both the brand name and primary protein)

Does your pet travel out of state with you?

Yes No

If so, where, how often, and what time of year?

Where does your pet sleep?

What kind of bedding is used?

Do you use any flea control or routine insecticides?

Yes No

If so, please list

Has your pet been diagnosed with any other medical conditions?

Yes No

If so, what condition(s)

Is your pet receiving any medication for this condition?

Yes No

Please list

Has bloodwork been recently completed on your pet?

Yes No

If so, when?

Has your pet recently demonstrated any of the following?

Coughing Runny Eyes Vomiting Diarrhea Decreased Activity Excessive Thirst Excessive Urination Loss of/or Decreased Appetite Other (Check any that apply)

Please explain if you selected other for the above question

Additional Comments:

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Referring information:

Patient Information:

Emergency

Midnight Sun Animal Hospital & Emergency Care

(907) 562-8384

Pet emergency treatment

(907) 274-5636