9220 Estero Park Commons Blvd · Suite 3 · Estero, FL 33928
info@animalderm.net
Hours: Mon-Thu 8:30-4:30 Fri 9-3
(239) 948-9434
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New Client Dermatology Form
*Please give us a call to schedule an appointment before filling out forms*
New Client Dermatology History Form
Patient History Form
Client’s Full Name
Pet’s Name
Reason for Visit:
Duration of problems:
Frequency:
Constant
Intermittent
Seasonal
Other
Observations: Check all that apply
Hair Loss
Foot Problems
Shakes Head
Bites Tail Area
Weight Gain
Itching
Nail Problems
Redness
Licks Stomach
Weight Loss
Vomiting
Skin Infections
Rubs Face
Scratches Sides
Sneezing
Tiredness
Diarrhea
Ear Infections
Hives
Rubs Back
Scratches Ears
Increased Thirst
Crusts/Sores
Licks/Chews Paws
Dandruff
Decreased Appetite
Watery or Red Eyes
Increased Urination
Increased Appetite
Current Diet:
How long on this diet?
Has the pet ever been on a special diet for the skin?
Yes
No
If so, which one?
For how long?
My pet also gets:
Table scraps
Treats
Rawhides
Supplements
Bones
Flavored Medication
Shampoo:
Frequency:
Are you able to bathe your pet at home?
Yes
No
Does bathing
Help
Make it worse
No change
Name of Flea control
How often?
Name of Heartworm prevention:
Has your pet always lived in Florida?
Yes
No
If the answer is no, where did pet live before?
When did pet move here?
If seasonal, how many months is pet here?
Cats Only:
Strictly indoor
Lanai only
Indoor/Outdoor
Do you have other pets in your home?
Yes
No
If yes, what kind?
Do they have skin problems?
Yes
No
Current Medications:
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