"*" indicates required fields Client's Name* First Last Pet's Name* Email Reason for visit Ears Skin Itching allergies Other How long have the skin/ear problems been present? Is the itch seasonal or present year long? If seasonal, which seasons are the worst? When are symptoms the worst? Indoors Outdoors After being on grass At night Other Is your pet exposed to stuffed dog beds, feather/down filled blankets/pillows? If so, please specify: What was the initial problem? Skin looked normal but was itchy Hair loss Rash Redness Other On what part of the body did the problem start? Has the problem spread? If so, what are the affected areas now? Please rank your pet’s level of itch: Normal Very mild itching/occasional episodes Mild itching/more frequent, does not itch while sleeping/playing/eating etc. Moderate itching/regular episodes, may occur at night Severe itching/prolonged episodes, may occur at night and while doing other activities Extreme and severe/almost continuous Please list all current medications and supplements:How often do you bathe your pet? What shampoo do you use? How often do you clean your pet’s ears? What type of cleaner do you use? Please list current flea/tick preventatives and when they were last given:Please list current brands of food, main ingredients in the food, and types of food (dry, wet, raw, treats, human food):How long has your pet been on the current diet? Are there any other problems other than skin/ears (sneezing, red/runny eyes, cough, etc.)?