Patient History Form Please answer the questions below and click submit. Patient History Form Owner InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number*Patient InformationHorse's Name*Sex*Breed*Age*Patient's Dermatological History1. 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), other8. 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 issues16. 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):*
