Patient History Form

*This form is to be completed by the owner after an appointment has been scheduled. This is not a referral form for referring veterinarians.

Please complete the form below and click submit.

Owner Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number*
Patient Information
Horse's Name*
Sex*
Breed*
Age*
Patient's Dermatological History
1. How old was your horse when you first observed signs of skin disease?*
2. How long has the skin disease been present?*
3. Do the signs of skin disease occur:*
- A. Seasonally*
- B. Year round
- C. Year round with seasonal exacerbation*
* If seasonal, which seasons are the worst:
4. Is your horse itchy, if so how itchy is your horse on a scale of 1-10 (with 1 indicating a normal horse and 10 indicating constant, severe itch):*
5. Where did the lesions first start and what did they first look like?*
6. What diagnostic tests have been performed so far? Including intradermal skin tests, serology, skin biopsies, food trials, blood work, etc:*
7. What were the results of the diagnostic tests done? Please provide copies of blood work, histopathology, etc:*
9. What medications is your horse currently taking? Please indicate the drug name, the mg dose you are giving, frequency and for how long you have been giving each medication:*
Examples: antibiotics (i.e. TMS), anti-inflammatories (i.e. dexamethasone, banamine, phenylbutazone), other
8. What systemic medications (drug name, dosage, duration) have been used so far and what was the response to each medication given?*
10. What topical medications have been used and what was the response to therapy?*
11. What topical medications are you currently using on your horse (fly sprays, shampoos, conditioners, sprays, ointments, etc):*
12. What is your horse's current diet? Concentrate and hay:*
13. Is your horse stalled? Please provide information about pasture conditions.*
14. Do you give your horse treats? If so, which ones?*
15. Is your horse showing other signs of illness?*
Examples: weight loss, weight gain, colic, diarrhea, weakness/low energy level, respiratory issues
16. When was your horse last vaccinated and what was your horse vaccinated against?*
17. Has your horse ever had an adverse reaction to any medications? If so, to which medication(s)? When did it happen and what signs did you observe?*
18. When was your horse last dewormed and with what product? What is your usual deworming protocol (frequency, drugs, fecal egg counts, etc):*

Owner Information

Patient Information

Patient's Dermatological History

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