PLEASE PRINT THIS PAGE, FILL IT OUT AND BRING IT WITH YOU TO YOUR FIRST APPOINTMENT  
Atlanta Veterinary Skin & Allergy Clinic, PC
           2803 Shallowford Road NE, Atlanta, GA  30341

                          PATIENT HISTORY

Client's Name_____________________________   Pet's Name________________    Date__________

Breed_______________ DOB/Age________  Sex_____  Spayed/Neutered? _____   At what age?_____

Last Rabies Vaccine Date  _______  Has your pet ever had a seizure?_____________

1.   How long has the problem been present?   ____________________________________________
2.   When did the problem first appear?   ________________________________________________
         -  Was the onset:   sudden________  or  gradual?_________
         - Is the problem continuous? (year-round) Yes____ No____; or  is it seasonal? Yes____ No____
       (if seasonal, when) Summer_____,   Fall_____,     Winter_____,     Spring____
        -  Are the symptoms worse:      Inside_____,    Outside_____ ,    or Both_____ ?
3.   When the problem first appeared, was it characterized by: (please check all that apply)
       Scratching____,    Biting____,    Chewing____,   Licking____,    Rubbing (face)____    Rubbing/ dragging bottom  ____?
       -  Was this activity:    Mild_____,    Moderate_____,    or  Severe  _____?
       -  Which areas of the body were most affected?   _______________________________________

       -  Please score this behavior from 0-10  with 0 being scratching like a normal healthy pet would and 10

          scratching all the time.   ________________
4.   Was there any hair loss? Yes ___No___.   If yes, was it: Undercoat____   or   Topcoat____ ?
       -  Which area(s) had the most hair loss?_____________________________________________
5.    Has there been an unusual odor associated with the condition?  Yes____ No____ 
       (Please describe)   __________________________________________________________________
6.   Color change of hair?  Yes____ No____ (please describe)  _________________________________
7.   Color change of skin?  Yes____ No____ (please describe)  _________________________________
8.   Change of texture in skin or hair?  Yes____No___(please describe)  __________________________
      _______________________________________________________________________
9.   Is there any dandruff? Yes______No_____ .    Is it:  Dry _____ or   Greasy____ to the touch?
10. Have you seen: Fleas _____,    Ticks_____,  or   Lice_____ on your pet?
       What are you using for Flea Control: ON YOUR PET ________________________________
       IN YOUR HOME______________________ IN YOUR YARD_________________________ ?
11. Have you seen: Hives_____,    Bumps_____,   Lumps_____,   or   Swellings_____  on your pet?
       Where __________________________________________________________________________
12. Is your pet exposed to tobacco smoke, Yes____No____,  or   House Plants?  Yes____No____                    
       (Please  describe) _______________________________________________________________
13. Do you have any other pets? (please check all that apply and how many of each) 
      Cats #________    Dogs#_______    Other#__________________________________________
      Do you, any family member, or any of the other pets have a skin problem? (Please list and  describe)   

              _____________________________________________________________________________
14.  What does your pet sleep on? (what materials)__________________________________________
15.  What brand of dry food does your pet eat?________________________ Canned food___________
       _____________  Pet treats__________________   Other pet foods___________________________
       -  What kind of dish does your pet eat from? (Plastic, glass, etc)  __________________________
       -  What kind of Toys does your pet have? (Rawhide, plastic bone, etc)  _____________________
       _____________________________________________________________________________
16.  What human table food does your pet eat?  _____________________________________________
       _________________________________ How often?____________________________________

17. Is your pet professionally groomed? Yes_____ No_____
      -  How often?  __________________________________________________________________
18.  How often do you bathe your pet?  ____________________________________________________
     - What shampoos do you use?  _____________________________________________________ 
     - When was the last bath given?  ___________________________________________________
19.  What treatment or drugs have been used for your pet's condition?  ___________________________
        _______________________________________________________________________________
     -  Describe the response: Better______ Worse______ No Change______
     -  What OTC or home remedies have you tried?_______________________________________
     -  Describe the response to these: Better______ Worse______ No Change_____
20.  What treatment is your pet currently receiving?_________________________________________
        _______________________________________________________________________________
21.  Has your pet ever had a drug reaction? Yes____ No____ (if yes, please list the drug(s) and describe the reaction)              

_________________________________________________________________
22.  Has your pet received steroids? (Cortisone, prednisone, etc.) Yes____ No____
     - Please list type/when: ___________________________________________________________________
     - Were they in an:   Injection_____,    Tablet/Liquid_____,    or  Topical______ form?
     - What was the response?_________________________________________________________
     - When were they last administered?________________________________________________
23.  Has your pet received any antihistamines? (benadryl, atarax, CPMs) Yes___ No____
    -  What kind?__________________________________________________________________
    - What was the response_________________________________________________________
    - When was it last administered?__________________________________________________
24.  Has your pet had any other illnesses or accidents, or is he/she CURRENTLY receiving medication  for another condition?  

       (Please describe and list medications) ______________________________________________________________  

       ___________________________________________________________________________________________
25.  Has there been a change in frequency, urgency, or volume of urination? Yes____ No____
        (please describe) ________________________ _________________________________________
26.  Has there been a change in water intake? Yes____ No_____;    More ____   or  Less ____
       -When did this begin?____________________; is it still ongoing?  Yes_____ No_____
27.  Has there been a change in activity level? Yes____ No_____;       More _____  or  Less____
      - When did this begin?____________________; is it still ongoing? Yes_____ No_____
28.  Has there been a change in behavior?(aggression, lethargy, etc.) Yes____ No_____
        (please describe)__________________________________________________________________
      -  When did this begin?____________; is it still ongoing? Yes____ No______
29.  Has there been a change in bowel habits and/or stool consistency? Yes____ No____
       (please describe)__________________________________________________________________
     - When did this begin?_____________; is it still ongoing?  Yes____ No_____
30. When was the last vaccination given?__________________________________________________
31.  What type of HEARTWORM PREVENTION are you using?_______________________________  Date of last HW test  _________
32.  Date of last RABIES VACCINATION _________________   (must be current)
        DATE OF LAST DHLPP/FVRCP  vaccination _____________________
33. FOR CATS ONLY: A Feline LEUKEMIA/FIV Test:    Has____ Has not____ been done;  Date ________ Results were: Pos FeLV/FIV___                    neg ___

COMMENTS AND OTHER CONCERNS     _________________________________________________________________

__________________________________________________________________________________________________