New Patient Charlotte – SouthEast Veterinary Dermatology

Primary Complaint

Owner's Name *

Occupation

Address *

City *

State *

Zip *

Phone (Preferred) *

Phone (Other)

Email

Pet's Name *

Date of Birth or Age *

Preferred Contact Method

Species *

Breed *

Color

Sex *

Spayed / Neutered?

May we use photos of your pet on Facebook?

Referring Family Veterinarian

Please list all veterinary clinics/specialty hospitals that your pet has seen in the last two years

DERMATOLOGY HISTORY QUESTIONNAIRE

Briefly describe your pet's problem(s)

How long has it been present? *

Approximate age of onset?

Progression of symptoms

Does your pet's skin and/or ear problem appear to be seasonal?

If yes, check all that apply

Spring

Summer

Fall

Winter

Affected areas - front feet / back feet / underarms / belly / ears / head / chin / neck / tail / other

Does your pet scratch, chew, or lick themselves excessively?

If so, where?

On a scale of 0-10, how itchy is your pet

What other pets are in the house?

Do any of the other pets have skin and/or ear problems?

Do any members of the household have unexplained skin problems? (rash, ringworm, etc)

What is your pet's current diet? *

How long has this been fed?

Is your pet mostly indoors, outdoors, or both?

What flea prevention do you currently use? *

Topical or Oral?

What flea treatments do you use in your house/yard?

What is your pet's current heartworm prevention? *

What are your pet's current treatments/medications?

Does your pet have any other health problems? (seizures, heart problems, etc.)

Email