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Dermatology History Form


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  • breeder   private home   shelter   breed rescue   stray

  • yes   no

  • yes   no

  • spring   summer   fall   winter

  • rash   itching   hair loss

  • nose   muzzle   eyes   ears   neck   back   rump
    tail   axilla(armpit)   front legs   rear legs   tops of paws
    webs of paws   chest   abdomen   groin   rectal area
    Other (Please explain)

  • yes   no



  • yes   no


  • trip   boarding   travel   illness




  • table food   raw hides   pig ears   biscuits/treats
    chewable meds   none
    Other (Please explain)

  • cough   sneeze   nasal discharge   eye discharge   vomiting
    poor appetite   ravenous appetite   increased thirst   head shaking
    exercise intolerance   increased urination   diarrhea   head tilt
    Other (Please explain)




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