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 by the Friday before your appointment at AADC so Dr. Nichols may review these at the same time he is studying your pet's medical history. Upon successful submission, you will immediately see a pop-up confirmation message. If you do not receive this confirmation, your form was not successfully submitted, and you need to double check your form for directions of needed corrections, then resubmit. Thank you so very much.
Name of owner(s) (required)
First Name (required)
Last Name (required)
Name of pet (required)

Date of Birth

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? :
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 :
Is your pet itchy? (i.e., does he/she scratch, rub, chew, lick, or bite themselves excessively?) :
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? :
If your pet is an intact male, does he have a normal interest in females? :
Are you aware of any relatives of your pet who have skin issues? if so, please describe.

Do you use flea control? :
If you use flea control, what type? :
How often is the flea control given or applied?

What is the name/brand of flea control?

Do you use heartwom preventative? :
If you use heartworm preventative, what type? :
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? :
If yes, which one(s)?

What is your pet's regular diet?

How long has this been their regular diet?

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

Does your pet ever receive treats? :
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? :
Has your pet had a decrease in appetite? :
Does your pet drink excessively? :
Does your pet urinate excessively or have accidents in the house? :
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.


Verify the reCAPTCHA: