VetMED Veterinary Hospital

202 N. Walnut St.
Bay City, MI 48706

(989)684-4877

vetmedhospital.com

Skin History Form

For your convenience, we recommend you to fill out the Skin History Form if you have an appointment with us to have a skin issue checked out. This will help the doctors be more prepared for your visit.

Skin History Form

Date (required) :
Name (required)
First Name (required)
Last Name (required)
Phone (required)
Phone TypePhone Number (required)
E-Mail Address :
Pets Information
Patients Name (required)

Patients Birth Date :
Sex (required)
Female
Male
Male/Neutered
Female/Spayed
Chief Complaint(s) (required)

Age pet was obtained. From where? I.E. breeder, shelter, rescue, etc. (required)

Age when the problem was noticed (required)

Onset (required) :
Rate Itching: 1-10 (1= occ. itch, 10= itching all day/night) (required) :
Does the animal itch? (required)
yes
no
When? (required)
Constant
Sporadic
Night
Is there a seasonal influence? Check all that apply. (required)
No
Spring
Summer
Fall
Winter
Where on the body did the problem begin? (required)

What did it look like initially? (required)

What other animals are in the household? Describe. (required)

Do other animals or people in the household have skin problems, rash? (required)
yes
no
Describe the animal's indoor environment, time (%). (required)

Describe the animal's outdoor environment, time (%). (required)

What diagnostic tests have been performed? Check all that apply. (required)
Skin Scrape
Skin Cytology
Ear Cytology
Culture and Sensitivity
Blood Work
Thyroid Testing
Other
No Testing Has Been Done
What topical treatment has been used? Success? (required)

What oral or injectable treatment(s) has been used? Success? (required)

When was the last time fleas were seen on any of the pets? (required)

Describe flea control being used? (required)

Animal's diet (including snacks & treats): (required)

Is the animal on any medications at present? (required)
yes
no
What other facts do you think would be helpful?

Appointment Time (if one has been scheduled) :

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