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Contact information:
* First Name:
* Last Name:
* Home Phone:
  Cell phone:
* E-mail:
  City, Zip Code:
Pet information:
Pet's Name:
Type of Pet: Dog Cat
Date of Birth:
Gender: Male Female
Spayed/Neutered: Yes No
Date when you acquired pet:
Where was your pet obtained:
Breeder Pet Store
Private Sale Humane Society
Ears Problems:
Any ears problems: Yes No
Which ear affected: Right Left Both
Problem Location:

Inside ear canal Outside ear
Canal (pinna) Skin behind ears
Tips of the ear
Any changes in ear skin color: Yes No
Itchy Pain
Odour Hair loss
Discharges Crust
Ulcer Growth/tumour
Head shaking
If ear itching occurs seasonally: Yes No
Ear discharges:
Wax Yellow/green
Black Bloody
Current Skin Problem(s):
Rash Hairloss Itching
Odour Other
If itching occurs seasonally: Yes No
Itching Degree:
Approximate Date
when problem FIRST started:
Onset Sudden Gradual
Are symptoms getting worse: Yes No
When did symptoms start to get worse:
Where on your pet's body did the problem FIRST begin, check all that apply
or click on pet's body picture for selection:
Muzzle Neck
Back Legs Back Paws
Groin Eyes
Back Armpits
Thighs Chest
Ears Tail
Front Legs Front Paws
Abdomen Chin
Nose Elbow
What did the problem look like initially:
Normal Skin, just "itch" Pimples
Hair Loss Redness
Has problem spread: Yes No
When/Season/Where did problem spread:
Have the ears been involved
(infected, waxy,itchy):
Yes No
General Health:
Any changes in weight: Yes No
If YES please select: Loss Gain
Any decrease in activity levels: Yes No
Any increase in drinking: Yes No
Any increase in urinating: Yes No
Any increase in appetite: Yes No
Any other medical conditions:
Any other pets in the household: Yes No
If YES please list:
Do they have any skin problems: Yes No
If YES please describe:
Do any people in the household have skin problems: Yes No
If YES please describe:
Does your dog go to doggy daycare, groomers, dog parks etc: Yes No
If YES please describe how often:
Previous Diagnostic Tests:
Please write relevant result briefly
Skin Scraping: Yes No
Blood CBC, Biochemistry: Yes No
Cytology: Yes No
Thyroid Evaluation: Yes No
Bacteria Culture: Yes No
Cushing Evaluation: Yes No
Fungal Culture: Yes No
Biopsy: Yes No
Wood Lampe: Yes No
Serum Allergy test: Yes No
Elimination Diet: Yes No
Drug History:
Drug Name When was it started? Did it help? When was it stopped?
Antihistamines (ie: Benadrylů) Yes No
Cortisone (ie:prednisone, VanectylP) Yes No
Cortisone Injections Yes No
Atopica/Neoral (Cyclosporine) Yes No
Antibiotics Yes No
What kind of Antibiotics
Shampoo Yes No
What kind of Shampoo
Flea Control Yes No
Heart Worm Meds Yes No
What kind of Heart Worm Meds
Ear Meds
Eye Meds
Topical Meds
Vaccination done? Yes No
Were there any adverse reactions to any of the above? Yes No
If YES, what were the symptoms?
Vomiting Diarrhea Skin got worse
Severe Itching Other
Name of your regular veterinarian who prescribed the medicine:
Address of veterinarian clinic:
Phone of veterinarian clinic:
Do you agree if we contact your regular veterinarian? Yes No
Food History:
List pet foods, treats (cookies, biscuits, chews, snacks etc) and human food:
If you want to send a picture of your pet please use email: mobilevetcare@gmail.com