"*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Owner's Name First Last Pet's NameWhat is the main reason for your visit today?Symptom HistoryAt approximately what age did the problem start?Have the symptoms gotten better, stayed the same, or gotten worse?Is the issue seasonal or year-round?What body areas are affected?Does your pet seem itchy (corn cob, chew, lick, scratch)? How bad on a scale of 1-10 (10- worse itch):Past & Current Skin/Ear ProblemsHas your pet had skin or ear problems before?Any history of Hair loss Redness or rash Bumps or sores Ear infections Head shaking or ear scratching Foul odor from skin or ears Treatments TriedList all medications, shampoos, sprays, ointments, or supplements you have tried for this problem (including over-the-counter products). Please include how long you used them and how well they worked:ProductDuration of UseEffectivity Add RemoveDiet & FeedingWhat brand of food does your pet eat and for how long have they been consuming it?BrandDuration of Use Add RemoveAny recent diet changes?Diet & Feeding:What brand of food does your pet eat and for how long have they been consuming it?BrandDuration of Use Add RemoveAny recent diet changes?Does your pet receive treats, table food, chews, flavored medications, or supplements? If so list?Flea/Tick PreventionWhat flea and tick prevention do you use?How often do you apply it?Medical HistoryAny known medication allergies?Any current medications? If so what ? Add RemoveSignature*Date* MM slash DD slash YYYY
