History questions for Ear Issues

Client Name:*

First Last

Pet(s) Name:*

Date and time of appointment:*

Please describe the problem you have noticed.*

How long have you noticed the symptoms? Is one ear worse? Is he/she painful? Is there an odor?*

Is this the first time this issue has occurred?*

Are they scratching or shaking their head a lot? If so, where is the itching focused?*

Do they have a recent history of swimming, bathing, or a moist environment?*

Are any other pets or people in the house affected?*

Was there a traumatic event, and if yes, when?*

Are they eating, drinking, urinating and defecating normally?*

What kind of food are you feeding? How much, how many times a day? How long has he/she been on this diet?*

Have they been coughing, sneezing, vomiting or had diarrhea?*

Are they on any medications or supplements, flea/tick/heartworm or other parasite prevention products?*

Do they have a history of reactions to vaccines or medications?*

For dogs: What is their lifestyle like? Does he/she participate in breeding, working, hunting, canine sports or obedience classes, daycare, boarding or grooming?*

For cats: What is their lifestyle like? Does he/she participate in breeding or showing, is he/she indoor only or indoor/outdoor?*

Do they travel outside of Maine? If so, where?*

Are there any other questions or concerns would you like to discuss with the doctor?*

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