PLEASE PRINT THIS PAGE, FILL IT OUT AND BRING IT WITH YOU TO YOUR FIRST APPOINTMENT
Atlanta Veterinary Skin & Allergy Clinic, PC
2803 Shallowford Road NE, Atlanta, GA 30341
Client's Name_____________________________ Pet's Name________________ Date__________
Breed_______________ DOB/Age________ Sex_____ Spayed/Neutered? _____ At what age?_____
Last Rabies Vaccine Date _______ Has your pet ever had a seizure?_____________
1. How long has the problem been present? ____________________________________________
2. When did the problem first appear? ________________________________________________
- Was the onset: sudden________ or gradual?_________
- Is the problem continuous? (year-round) Yes____ No____; or is it seasonal? Yes____ No____
(if seasonal, when) Summer_____, Fall_____, Winter_____, Spring____
- Are the symptoms worse: Inside_____, Outside_____ , or Both_____ ?
3. When the problem first appeared, was it characterized by: (please check all that apply)
Scratching____, Biting____, Chewing____, Licking____, Rubbing (face)____ Rubbing/ dragging bottom ____?
- Was this activity: Mild_____, Moderate_____, or Severe _____?
- Which areas of the body were most affected? _______________________________________
- Please score this behavior from 0-10 with 0 being scratching like a normal healthy pet would and 10
scratching all the time. ________________
4. Was there any hair loss? Yes ___No___. If yes, was it: Undercoat____ or Topcoat____ ?
- Which area(s) had the most hair loss?_____________________________________________
5. Has there been an unusual odor associated with the condition? Yes____ No____
(Please describe) __________________________________________________________________
6. Color change of hair? Yes____ No____ (please describe) _________________________________
7. Color change of skin? Yes____ No____ (please describe) _________________________________
8. Change of texture in skin or hair? Yes____No___(please describe) __________________________
9. Is there any dandruff? Yes______No_____ . Is it: Dry _____ or Greasy____ to the touch?
10. Have you seen: Fleas _____, Ticks_____, or Lice_____ on your pet?
What are you using for Flea Control: ON YOUR PET ________________________________
IN YOUR HOME______________________ IN YOUR YARD_________________________ ?
11. Have you seen: Hives_____, Bumps_____, Lumps_____, or Swellings_____ on your pet?
12. Is your pet exposed to tobacco smoke, Yes____No____, or House Plants? Yes____No____
(Please describe) _______________________________________________________________
13. Do you have any other pets? (please check all that apply and how many of each)
Cats #________ Dogs#_______ Other#__________________________________________
Do you, any family member, or any of the other pets have a skin problem? (Please list and describe)
14. What does your pet sleep on? (what materials)__________________________________________
15. What brand of dry food does your pet eat?________________________ Canned food___________
_____________ Pet treats__________________ Other pet foods___________________________
- What kind of dish does your pet eat from? (Plastic, glass, etc) __________________________
- What kind of Toys does your pet have? (Rawhide, plastic bone, etc) _____________________
16. What human table food does your pet eat? _____________________________________________
_________________________________ How often?____________________________________
17. Is your pet professionally groomed? Yes_____ No_____
- How often? __________________________________________________________________
18. How often do you bathe your pet? ____________________________________________________
- What shampoos do you use? _____________________________________________________
- When was the last bath given? ___________________________________________________
19. What treatment or drugs have been used for your pet's condition? ___________________________
- Describe the response: Better______ Worse______ No Change______
- What OTC or home remedies have you tried?_______________________________________
- Describe the response to these: Better______ Worse______ No Change_____
20. What treatment is your pet currently receiving?_________________________________________
21. Has your pet ever had a drug reaction? Yes____ No____ (if yes, please list the drug(s) and describe the reaction)
22. Has your pet received steroids? (Cortisone, prednisone, etc.) Yes____ No____
- Please list type/when: ___________________________________________________________________
- Were they in an: Injection_____, Tablet/Liquid_____, or Topical______ form?
- What was the response?_________________________________________________________
- When were they last administered?________________________________________________
23. Has your pet received any antihistamines? (benadryl, atarax, CPMs) Yes___ No____
- What kind?__________________________________________________________________
- What was the response_________________________________________________________
- When was it last administered?__________________________________________________
24. Has your pet had any other illnesses or accidents, or is he/she CURRENTLY receiving medication for another condition?
(Please describe and list medications) ______________________________________________________________
25. Has there been a change in frequency, urgency, or volume of urination? Yes____ No____
(please describe) ________________________ _________________________________________
26. Has there been a change in water intake? Yes____ No_____; More ____ or Less ____
-When did this begin?____________________; is it still ongoing? Yes_____ No_____
27. Has there been a change in activity level? Yes____ No_____; More _____ or Less____
- When did this begin?____________________; is it still ongoing? Yes_____ No_____
28. Has there been a change in behavior?(aggression, lethargy, etc.) Yes____ No_____
- When did this begin?____________; is it still ongoing? Yes____ No______
29. Has there been a change in bowel habits and/or stool consistency? Yes____ No____
- When did this begin?_____________; is it still ongoing? Yes____ No_____
30. When was the last vaccination given?__________________________________________________
31. What type of HEARTWORM PREVENTION are you using?_______________________________ Date of last HW test _________
32. Date of last RABIES VACCINATION _________________ (must be current)
DATE OF LAST DHLPP/FVRCP vaccination _____________________
33. FOR CATS ONLY: A Feline LEUKEMIA/FIV Test: Has____ Has not____ been done; Date ________ Results were: Pos FeLV/FIV___ neg ___
COMMENTS AND OTHER CONCERNS _________________________________________________________________