Ancient Arts Holistic Veterinary Services, PLLC
110 N. 36th Street Seattle, WA 98103
Phone: 206-547-1025 Fax: 206-547-1325
Dermatology History Form
Please return completed form by one week prior to appt. via fax 206-547-1325 or email .
If you arrive without completed paperwork, the time taken to fill out the forms will take away from doctor time.
Patient Name: ______Age: ______
Owner Name:______Breed: ______
Owner’s chief complaint:
Ancient Arts Holistic Veterinary Services, PLLC
110 N. 36th Street Seattle, WA 98103
Phone: 206-547-1025 Fax: 206-547-1325
_____Itching
_____Sores
____Ear ____Scratching/Infection
____Hair Loss
Ancient Arts Holistic Veterinary Services, PLLC
110 N. 36th Street Seattle, WA 98103
Phone: 206-547-1025 Fax: 206-547-1325
When was the issued first noticed: ______
Where on the body did the issue first appear: ______
Has the issue spread to other parts of the body?
If so, explain: ______
When is the issue present?
Ancient Arts Holistic Veterinary Services, PLLC
110 N. 36th Street Seattle, WA 98103
Phone: 206-547-1025 Fax: 206-547-1325
____Year-round
____Seasonal
Ancient Arts Holistic Veterinary Services, PLLC
110 N. 36th Street Seattle, WA 98103
Phone: 206-547-1025 Fax: 206-547-1325
When is it worse: ______Better:______
What kind of flea control is your pet on: ______
How frequently does your pet receive it: ______
Any reactions to flea medication in the past: ______
What kind of reaction: ______
Is your pet itching (scratching/licking/chewing/rubbing/etc.)?
Ancient Arts Holistic Veterinary Services, PLLC
110 N. 36th Street Seattle, WA 98103
Phone: 206-547-1025 Fax: 206-547-1325
____No
____Yes
Ancient Arts Holistic Veterinary Services, PLLC
110 N. 36th Street Seattle, WA 98103
Phone: 206-547-1025 Fax: 206-547-1325
How bad is the itching on a scale of 1-10? ______
(1 = not bad5 = moderate10 = severe, constant)
Where is your pet itching?
Ancient Arts Holistic Veterinary Services, PLLC
110 N. 36th Street Seattle, WA 98103
Phone: 206-547-1025 Fax: 206-547-1325
____Eyes
____Ears
____Face
____Lower Back/Hips/ Rump/Base of Tail
____Shoulders
____Belly/Groin
____Arm Pits
____Front Legs/Feet
____Back Legs/ Feet
____Edge of Rib Cage/Flank
Ancient Arts Holistic Veterinary Services, PLLC
110 N. 36th Street Seattle, WA 98103
Phone: 206-547-1025 Fax: 206-547-1325
Are there any other pets in the home?______
If so, are they affected by the same issue?______
Has your pet been seen elsewhere for this issue? ______
If so, please list the locations so that we may get past records: ______
List any medications and/or supplements that have been used for this issue: ______
Provide any information, observations, and concern that you feel the doctor should be aware of: ______
Flea prevention is still the number one priority in treating skin issues. Second is topical therapy, including baths, cool water rinses, and skin-protecting oils.
We understand that skin issues can be frustrating for all involved. We will do all that we are able to resolve the issue as soon as possible, but we will need the owner’s cooperation with at-home care and understanding that skin issues can take a long time to resolve.
Skin is the largest organ of the body and a major route of detox as well as absorption of pollens and irritants. The skin and coat health reflects the overall health of a patient’s gut, liver, and mental health.
There are a few great dermatology specialists in the area that would also be excellent referrals at any time for you to pursue:
Dermatology Center for Animals (Seattle)Dr. Mel
Animal Skin & Allergy Clinic(Lynnwood)Dr. Duclos
Animal Dermatology Services(Edmonds)Dr. Mundell
Animal Dermatology Clinic--Blue Pearl Animal
Critical Care & Emergency Services (Renton)