Dermatology History Online Form Dermatology HistoryOwner's Name* First Last Pet Name* First Date of Appointment* MM slash DD slash YYYY What age did you first notice the problem?* Is the problem year round or worse during a particular time of year?* Year Round Winter Spring Summer Fall What did the problem look like when it first started?* Scratching Hair Loss Rash Redness Other If other please explainWhere did it start? (Choose all that apply.)*NoseEyesEarsNeckBackRumpLegsPawsChestStomachGroinTail If your on a keyboard, hold "CTRL" and select multiple.Any other pets or people with skin issues in your home?* Yes No If yes, please describe:What percentage of your pet's time is spent indoor or outdoors?*Indoor %Outdoor %Has there been a change in diet?* Yes No If yes, please describe:Is your pet on flea medication?* Yes No If yes, what kind? CAPTCHANameThis field is for validation purposes and should be left unchanged.