Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Primary Care Veterinarian Pet's Name* Breed* Age* SexPlease SelectMaleFemaleWeight*Pet TypePlease SelectCanineFelineCondition* Intact Neutered Spayed 1. Describe the skin problem you are bringing your pet in for:*2. How old was your pet when the skin problem first started? **3. Did the problem start suddenly or gradually over time? **4. Is the problem (select one):* All Year Round Intermittent 5. Is the problem worse during certain times of the year?* Yes No If yes, when (select all that apply)? Spring Summer Fall Winter 6. Has your pet ever had an ear infection?* Yes No If yes, when (select all that apply)? Spring Summer Fall Winter 7. Is your pet itchy (this includes any licking, chewing, rubbing, biting, or scratching)?* Yes No 8. Rate your pet’s level of itch on a scale of 0 (no itch) to 10 (your pet’s most severe itch). Write a number 1 to 10* 9. List the locations on your pet’s body where they are itchy* 10. What did you notice first (select one)?* Skin Lesions Itch Both 11. List ALL medications your pet is CURRENTLY taking (including any topicals , supplements, or medications for other conditions not related to the skin). Indicate the response to these treatments if known.*12. List PREVIOUS medications used to treat your pet’s skin/ears (including any topicals or supplements) . Indicate the response to these treatments if known.*13. Is your pet primarily (select one):* Indoor Outdoor Both 14. What flea/tick prevention are you using (list type)?* Year Round Seasonally None If you are using flea/tick prevention, what brand/type you are using?15. What heartworm prevention are you using?* Year Round Seasonally None If you are using heartworm prevention, what brand/type are you using?16. Do you have other pets in your household?* Yes No If yes, what type?*Are the other pets primarily:* Indoor Outdoor Both Are the other pets in the household receiving flea/tick prevention?* Yes No List Type17. Does your pet have contact with any animals outside of your home (list location and types of animals) (Ex. Dog daycare, boarding, etc.)?*18. Do any other pets or people in the household have skin problems?* Yes No 19. What do you feed your pet (include treats, chews, table food, etc.)?* 20. Does your pet have a sensitive stomach associated with feeding different types of food (ex. vomiting, diarrhea, etc.)?* Yes No 21. Have different diets been tried as treatment (list brand name & duration given)?* 22. Does your pet have any travel history (list location)?* Yes No List location23. List any other diagnosed medical illnesses:
