Animal Allergy & Dermatology Center of Central TX

2207 Lake Austin Boulevard
Austin, TX 78703

(512)477-4824

www.aadcaustin.com

NEW PATIENT Form


Please complete and submit both the "New Client" and the "New Patient" forms immediately after making your appointment with AADC so Dr. Nichols may review these at the same time he is studying your pet's medical history. We must receive these forms a minimum of a week prior to your appointment. Upon successful submission, you will immediately receive a confirmation message. If you do not see this confirmation on your screen, your form was not successfully submitted, and you need to double check your form then resubmit. Thank you.
Name(s) of owner(s)

Name of pet

Pet's date of birth or approximate age

Age of pet when you acquired him/her

Main concern

Approximate date and/or pet's age when problem first started

Is the problem seasonal or continuous?

If the problem is now continuous, was it initially seasonal? (click one choice) :
Is there a time of year when the problem is less severe or the itching is less intense?

Have you traveled out of the area, state, or country with your pet? if so, where?

During that time, was your pet's skin (click one choice) :
Is your pet itchy? i.e., does he/she scratch, rub, chew, lick, or bite themselves excessively? (click one choice) :
If yes, please list all the affected sites (e.g., face/muzzle, eyes, ears, back, rump, tail, armpits, elbows, front legs, back legs, thighs, front paws, back paws, chest, belly, groin, anal area.)

Comments about sites affected

Do you have other pets in the household? If so, please describe.

Do any of your other pets have skin issues? If so, please describe.

Do any people in the household have skin issues? If so, please describe.

What percentage of the time is the pet kept indoors?

What percentage of the time is the pet kept outdoors?

When are your pet's symptoms the worst (e.g. indoors, outdoors, after pet comes indoors after being out, at night, in the morning.)

Is your pet intact or neutered? If neutered, at what age?

If female, do they or did they have normal heat cycles? (cick one choice) :
If your pet is an intact male, does he have a normal interest in females? (click one choice) :
Are you aware of any relatives of your pet who have skin issues? if so, please describe.

Do you use flea control? (click one choice) :
If you use flea control, what type? (click one choice) :
How often is the flea control given or applied?

What is the name/brand of flea control?

Do you use heartwom preventative? (click one choice) :
If you use heartworm preventative, what type? (click one choice) :
How often is the heartworm preventative given or applied?

What is the name/brand of heartworm preventative?

Please list all medications your pet has been given for their skin issues.

Did any medications help their skin issues? (click one choice) :
If yes, which one(s)?

What is the Brand Name and Protein Source of your pet's regular food?

How long has this been their regular diet?

Does your pet ever receive people food? (click one choice) :
If yes, what type(s)?

Does your pet ever receive treats? (click one choice) :
If yes, what type(s)? (e.g. biscuits, rawhides, pig ears, cow hooves)

Please list any other treats/dietary supplements your pet receives.

On average, how many bowel movements does your pet have per day?

Has your pet had an increase in appetite? (click one choice) :
Has your pet had a decrease in appetite? (click one choice) :
Does your pet drink excessively? (click one choice) :
Does your pet urinate excessively or have accidents in the house? (click one choice) :
If yes to any of the above, specify how long each issue has been occuring.

Please advise of any other medical conditions, diseases, etc. that may be present.

Please provide any other information you feel may be helpful.


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