DIETARY HISTORY QUESTIONNAIRE

In addition to answering the following questions, please also submit pictures of the ingredient labels of all currently fed dry food, wet food, chews, cookies, treats etc. Alternatively, you may bring all the foods and treats offered to your pet to your first appointment.

Does your pet get any human food (specifically cooked for pet or offered from food prepared for family members)?
YesNo
If YES, how often?
If YES, please list what types of human food is offered to your pet?
Does your pet frequently get into garbage or eat things outdoors?
YesNo
Does your pet spend time outdoors without your direct supervision?
YesNo
Have you pursued a diet elimination trial or changed any of the food or treats for your pet in order to help improve the dermatologic concerns?
YesNo
If YES:
Did you observe an improvement in your pet’s itching/symptoms?
YesNo
Did you observe an aggravation in your pet’s itching/symptoms?
YesNo
Do you feel that your pet may have some type food allergy?
YesNo
Thank you for taking the time to provide us with feedback regarding your pet’s dietary history. If you would like to offer additional feedback, please provide it in the following space:

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