Animal Doctor Westside Your Other Family Doctor EAR ISSUES First name * Last name * Preferred contact number. * Patient name * NEW PATIENTS ONLY: How long have you had the patient? NEW PATIENTS ONLY: Where did you get him/her? NEW PATIENTS ONLY: Is the patient microchipped? Yes No Unsure NEW PATIENTS ONLY: Vaccination history (be specific) NEW PATIENTS ONLY: Does the patient have any underlying conditions? Yes No Unsure NEW PATIENTS ONLY: If yes, please explain. How long have you noticed a problem with the ears? * Which ears are affected? * Left Right Both How is the pet behaving? Scratching, shaking, or in pain? * Has your pet had previous problems with the ears? Please explain. * CATS ONLY: How often does your cat go outside? Does he/she go outside on a leash or on a screened in porch? Has your pet been recently bathed or gone swimming? * Have you tried anything at home? When is the last time you cleaned the ears? * Any history of allergies? * What kind of food are you feeding? How much per day? Table scraps/ treats? * Is the patient on any medications? Include dosage and frequency. * Are you administering heartworm preventative? What type and how often? * Are you administering flea/ tick preventative? What type and how often? * Do you have any additional questions or concerns you would like to address with the Doctor today? * Submit If you are human, leave this field blank.