NameThis field is for validation purposes and should be left unchanged.Patient's NameClient's Name First Last Reason for Visit (Check all that apply) Ears Skin Hair loss Itching Allergies Other How long have the issues been present?Is this the first occurrence? Yes No If NO, are the issues year round or seasonal? Year Round Seasonal If seasonal, Which seasons are the worst?Are symptoms worse at any specific time/place? (Examples: Indoors, Outdoors, After being in grass, at night, etc.)On what part of the body did the problem start?Has the problem spread? If so, where?Please rank your pet’s level of itch: Normal Very mild, occassional Mild, does not itch while playing/eating/sleeping Moderate, may occur at night Severe, prolonged episodes, may occur at night or while doing other activities Extreme and severe, almost continuous Please list all medications or supplements:How often do you bathe your pet? What shampoo do you use?Has there been any change or new fragrances used in home or on pet? (examples: air fresheners, cologne, shampoos, cleaners)How often do you clean your pet’s ears? What cleaner do you use?Please list current flea/tick prevention and date of last dose:Please list current brand of food, type, and main ingredients (ex: chicken, pork, wet, dry, treats, human food, raw)Any recent diet changes or new foods?Are there any other symptoms? (example: sneezing, red/runny eyes, cough)Has there been any changes in body appearance? (weight change, coat change, etc)Has there been any change in amount of drinking, eating, urinations or defecations?
