The AMC Dermatology History Form

If you do not yet have an appointment, please call The AMC at (212) 838-7053 to schedule one. Only fill out this form if you have an appointment scheduled with us.
After you have made your appointment and prior to your visit to The AMC, please fill out and submit the following information to us. Doing so will speed your visit, since we will already have your information and your pet's information on file when you arrive. Fields marked with a red asterisk (*) are required.
Note: The AMC does not release personal information to any third parties.
*Client Name *Client Phone # Blue Card #
*Pet’s Name *Appointment Date
Pet’s Age Sex Breed
     
Questions About Your Pet
 
1. What is the skin problem?
Itching
Loss of Hair
Rash
Oily Skin

Dry Skin
Dandruff
Redness
Odor

Other
 2. When did you first notice the problem?
 
 3. Are the symptoms worse any time of year?
Spring
Summer
Fall
Winter
4. What did the problem look like when it first started?
Itching
Loss of Hair
Rash
Pimples
Redness
Other
5. Where did it start?
Nose
Eyes
Ears
Neck

Back
Tail
Rump
Legs

Paws
Chest
Stomach
Groin
6. Has it spread?
Yes, If so, Where? Explain
No
7. Does your pet scratch, rub, chew, lick or bite?
No
Yes, If Yes, Where?
Nose
Muzzle
Eyes
Ears 		Neck
Back
Rump
Tail 		Axilla (“Arm Pit”)
Front Legs
Back Legs
Paws 		Chest
Abdomen
Groin
 8. Was itching the first thing noticed?
Yes
No
 9. Do you have other pets in the house?
List
 10. Do they have any skin problems?
Explain
11. Do any people in your household have a skin problem?
Explain
12. Has your pet been neutered?
Yes (If so, What age?)
No
13. If female, has she had normal heat cycles?
Yes,
(If so, when last appeared?) Any Problems?
No
14. Has your pet been out of his/her normal area (Vacation/visit/boarded, etc.)?
Yes
(If so, where?) When?
No
15. What medication(s) has your pet been using since the problem started?
Oral
Topical
Injection
16. Did these medications help or cure the problem?
Yes
No
Some
For a while
17. What type and brand of food do you feed your pet?
Canned
Dry
Table Scraps
Other
18. Does your pet do or have any of the following?
 
Cough
Sneeze
Runny Nose
Runny Eyes 		Vomit
Diarrhea
Poor Appetite
Excessive Appetite		 Regular Exercise
Worms
Shake Head
19. Has your pet had any other illnesses?
Explain

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