Name of owner

Owner's phone

Owner's email

Referring vet

Vet's phone number

Name of horse

Breed of horse

DERMATOLOGY HISTORY

Age of horse

Does the horse travel? Does the horse travel? Yes No

Where?

How long have you owned this horse?

What is the main reason for your visit?

How long has your horse had this problem?

Is this the first time your horse has had a skin/ear/hoof/mane/tail problem? Is this the first time your horse has had a skin/ear/hoof/mane/tail problem? Yes No

When was the first occurrence?

Is your horse itchy? Is your horse itchy? Yes No

If you answered yes, does your horse scratch, lick chew or rub any of the following areas? Please tick all that apply: If you answered yes, does your horse scratch, lick chew or rub any of the following areas? Please tick all that apply: Head Ears Around Eyes Abdomen Back Neck Groin Rump Front Legs Withers Back Legs Mane Tail Chest Other

Other? Please describe

Is this problem seasonal? Is this problem seasonal? Yes No Unsure

What is this horse's use?

Please describe

Percentage of time spent stabled?

Has your horse experienced hives before? Has your horse experienced hives before? Yes No

If you answer YES to being seasonal, which seasons? If you answer YES to being seasonal, which seasons? Spring Summer Autumn Winter

Where does the horse spend most of it's time?

List the vegetation in the paddock

Are there any other animals on the property? Are there any other animals on the property? Yes No

Type of bedding

Please include species

Any other animals on the property affected? Any other animals on the property affected? Yes No

Are any humans in contact with the horse affected? Are any humans in contact with the horse affected? Yes No

Do any relatives of the horse have skin issues? Do any relatives of the horse have skin issues? Yes No Unsure

MEDICATIONS

Is your horse taking any medications currently? Is your horse taking any medications currently? Yes No

Please list

What medications has your horse received in the past for this issue?

Which medications seem to help?

Has your horse had any adverse drug or vaccination reactions before Has your horse had any adverse drug or vaccination reactions before Yes No

Are symptoms any worse when: Are symptoms any worse when: stabled outdoors in the morning at night

Do you use routine insect control for your horse? Do you use routine insect control for your horse? Yes No

Brand of insect treatment

How often do you wash your horse?

Brand of shampoo/conditioner

DIET

Please list all current diets, and include treats and supplements:

Has your horse been on a food trial? Has your horse been on a food trial? Yes No Unknown

GENERAL HEALTH

Has your horse had any previous illness, surgery or trauma Has your horse had any previous illness, surgery or trauma Yes No

Please describe

If YES, describe

Does your horse exhibit any of the following? Does your horse exhibit any of the following? Behaviour changes Diarrhoea Sneezing Coughing Runny eyes Drinking excessively Urinating excessively Change in weight

List any additional information that you feel is relevant to the skin disease:

SOCIAL MEDIA

Can we take photos of your horse and use them on our social media, website or for teaching? Can we take photos of your horse and use them on our social media, website or for teaching? Yes No

Please insert Instagram / Facebook names here

Do you or your horse have an Instagram or Facebook account we can follow? Do you or your horse have an Instagram or Facebook account we can follow? Yes No