History Check

    Owner and Patient Information

    Last Name*

    First Name*

    Phone Number*


    Pet Name*

    Your Pet's Breed*

    Pet Birthdate*


    Pet Sex*

    When did you acquire your pet?*

    Where did you acquire your pet?*

    Do you have pet insurance?*

    Does your insurance cover allergies/skin conditions?*


    What is your most important concern?*

    When did the problem start?*

    What was the first symptom and how did it start?*

    Is there a time of the year when the problem is worse?

    Has your pet ever had a severe allergic reaction?*

    Has your pet had an ear infection?*

    If yes to ear infections, how many and how often are the ear infections?

    Does your pet focus on any of the following issues?

    Which parts of its body does your pet focus on?*

    What is your pet's current itch score?

    Moderate Itching (Frequent Episodes):
    My dog is itching occasionally throughout the day but is not itching while eating playing, sleeping or whie being distracted. Itching ensues at night when observed.


    Current Medications: names, doses and frequency. Length of prescription. Any other details.*

    Past Medications: names, doses and frequency. Length of prescription. Any other details.*

    Habits and Diet

    What are your pet's bowel movements like?*

    What is the size of your pet's bowel movements?*

    Frequency/number per day?*

    What is your pet currently eating? Include treats, human food, and / or supplements.*

    What other diets have you tried in the past and what changes were noted with these diets?*

    Additional Information

    Can you give your pet oral medications?*

    Can you bathe your pet?*

    How often do you bathe your pet and what type of shampoo do you use?

    Can you give your pet ear medication?*

    Are there any other animals in the home?*

    If there are other pets in the home, what type are they and do they have any skin, allergy and/or ear conditions?

    Does your pet have any other illness or conditions?

    What are your goals for your upcoming appointment?*

    Relevant Images of Skin or Medical History

    Files must be smaller than 5mb. If your file is larger than 5mb, please email it directly to referrals@petderm.ca.

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