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Client History Form
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Indicates required field
Owner's Name
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First
Last
Phone number
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Email
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Pet's Name
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Presenting Complaint
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Why are we seeing your pet?
How long has the problem been present?
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How old was your pet when the problem started?
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When the problem started, did it start suddenly, or gradually over a period of time?
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What did the skin or ear problem look like initially?
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How has it changed or spread?
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Have the problems been (check one):
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Continual, with medication
Continual, but better on medication
Intermittent or sporadic
Is the problem worse during certain times of the year? If so, when?
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On a scale of 1 to 10, where 1 means occasional scratching (like a normal animal), and 10 represents constant, severe scratching, how itchy has your pet been in the last month?
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In the last 6 months?
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What heartworm prevention does your pet take?
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What flea/tick medication does your pet take? How often?
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Is your pet receiving any medication currently? If so, please list the name of the medication, strength, and frequency of administration.
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Is your pet being treated by other doctors/specialists? If so, please list the doctor and/or hospital involved.
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Other than skin/ear disease, does your pet have any diagnosed medical problems?
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IBD? Seizures? Other?
What food do you currently feed your pet?
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Have you tried other diets previously? If so, please indicate the brand and how long you fed that diet.
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How often do you bathe your pet?
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What products do you use to bathe/groom your pet?
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How old was your pet when you obtained him/her?
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Where was your pet obtained?
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breeder? pet store? rescue organization?
Are there other pets in the household? Please list.
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Do any of the other pets have skin problems?
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Do the humans in the house have skin problems?
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What percentage of the day does your pet spend outdoors?
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What percentage of the day does your pet spend indoors?
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Is there any other information you feel might be helpful?
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Permission to Photograph
I grant to Animal Allergy & Dermatology Center of Indiana, LLC (AADCI), the exclusive right to take photographs of my pet(s). I authorize AADCI, it's assignees, and transferees, to copyright, use and publish the same in print and/or electronically.
I agree that AADCI may use such photographs of my pet with or without my name for any lawful purpose, including such purposes as teaching, publications, illustration, advertising, and internet content.
Examples of such use: AADCI Facebook posts, website photo gallergy, in lectures given to other veterinarians, students, and interns.
Printed Name
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First
Last
I have read and understand the above:
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Yes
No
For the following symptoms, please check which symptoms have been present and how severe they have been over the entire course of the pet's skin or ear problem(s). Please check only ONE box for each symptom.
Scratching/licking/biting of self
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None
Slight
Moderate
Severe
Hair loss or poor regrowth of hair
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None
Slight
Moderate
Severe
Small red spots, pimples, bumps, rash
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None
Slight
Moderate
Severe
Dandruff, flakiness, scaliness of the skin
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None
Slight
Moderate
Severe
Increased odor of skin or coat
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None
Slight
Moderate
Severe
Open, raw sores that ooze blood or pus
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None
Slight
Moderate
Severe
Eyes - redness, irritation, itching, discharge
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None
Slight
Moderate
Severe
Change in color or texture of hair
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None
Slight
Moderate
Severe
Pigment change (light to dark or vice versa)
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None
Slight
Moderate
Severe
Ear Infections
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None
Occasional
Frequent
Always
Diarrhea or loose stool
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None
Occasional
Frequent
Always
Vomiting
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None
Rare
Occasional
Severe
Sneezing or wheezing
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None
Slight
Occasional
Severe
Changes in pet's personality
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None
Slight
Moderate
Severe
Changes in pet's activity level?
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None
Increased activity
Decreased activity
Weight loss or weight gain
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None
Weight gain
Weight loss
Changes in pet's appetite
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None
Increased
Decreased
Change in amount of water consumed
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None
Increased
Decreased
Change in urinary habits
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None
Increased
Decreased
Having accidents in the house
Frequent UTI's
For each body area, please choose whether your pet is not itchy, mildly itchy, moderately itchy, or severely itchy?
Feet/Paws
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None
Mild
Moderate
Severe
Legs/Arms
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None
Mild
Moderate
Severe
Abdomen (belly)/genital areas
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None
Mild
Moderate
Severe
Armpits/chest/sides of body
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None
Mild
Moderate
Severe
Face/Eyes
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None
Mild
Moderate
Severe
The tail
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None
Mild
Moderate
Severe
Anal area
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None
Mild
Moderate
Severe
It is important that we know which types of medications have been given to your pet in the past, and whether or not they were helpful in providing relief. For the list of medications below, please check whether or not your pet has received these medications previously.
Choose Any That Apply
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Apoquel
Cytopoint
Atopica (cyclosporine)
Allergy immunotherapy injections (ASIT)
Antifungal (ketoconazole, fluconazole)
Antibiotics alone (no other medication at the same time)
Antihistamines (Benadryl, Zyrtec, etc.)
Cortisone pills (steroids)
Cortisone injections
None of the above
For the medications that were tried above, please indicate whether or not the medication was helpful.
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Prescription Refills
Meet the Team!
Client Forms
Online Pharmacy
Referring Veterinarians
rDVM Consultation Request
Contact
Client Resources
