Initial Questionnaire - Canine Dermatology

IMPORTANT NOTES:

1) Itchiness in pets includes the following: Itching, Scratching, Licking, Chewing, Biting, Rubbing, Scooting (rubbing of hind end), and Head Shaking.

2) Ears and paws are a common target for allergies. Some dogs may have ahistory of ear infections or paw licking/biting before other areas of skin become involved.For questions relating to your dogs “skin” please includepaws and ears in consideration to your answer.

3) This questionnaire is intended to prepare yourself and Dr.Bajwa for your appointment. Please send back the filled out questionnaire to the hospital at least 2 days before your scheduled appointment.

4) If you do not know the answer to a question or do not understand the question please leave the answer blank. DO NOT guess.

    GENERAL INFORMATION
    Age or Date you acquired your pet:
    Have you recently moved with your pet?
    YesNoInternational
    If YES, please provide details including the timing of the move:
    If YES please provide details:
    Has your pet had any allergy testing done previously?
    YesNo
    If YES, where and when?
    A) SYSTEMIC (GENERAL) HISTORY
    Have you noted a loss in your pet’s weight?
    YesNo
    Have you noted weight gain in your pet?
    YesNo
    Have there been any changes in your pet’s activity levels?
    YesNo
    Have there been any changes in your pet’s energy levels?
    YesNo
    Have you noticed any changes in your pet’s thirst or urination habits?
    YesNo
    Has your pet received treatments for intestinal problems/upset in the past?
    YesNo
    Has your pet had/or currently have any of the following symptoms?
    VomitingGas/FlatulenceDiarrheaSoft StoolsBad BreathInappetanceBorborygmus (rumbling or gurgling intestinal sounds)None
    How many bowel movements does your dog have per day?
    Have you noticed any of the following symptoms in your pet?
    Runny EyesRedness of EyesRunny NoseSneezingCoughingSnoringReverse sneezingLabored BreathingNone
    Does your pet have any non-dermatology related health conditions or illnesses? If so please provide details:
    B) INFORMATION ON DERMATOLOGIC SYMPTOMS
    Approximate date or age of when your pet’s symptoms FIRST started
    If problem has been continuous for over a year, did it start off as seasonal?
    YesNo
    How itchy is your dog currently on a scale of 1 to 10? (Please use the Canine Pruritus Analog Scale to help in assessment of your dog's itch score)
    Are symptoms getting worse?
    YesNo
    Is there a time when your pet is more or less itchy?
    YesNo
    If yes, please provide more details on variations in itch:
    Was the “itchiness” the first symptom you noticed?
    YesNo
    Where does your pet itch? Please check all that apply and circle the worst areas.
    Face and MuzzleEyesEarsNeckHeadFront LegsFront PawsBack PawsArmpitsGroinTop of BackChestUnderbellyAnal area

    C) INFORMATION ON ENVIRONMENT
    How much time does your pet spend:
    %
    %
    Type of flooring in your residence:
    %
    %
    Where does your dog sleep? Please check all that apply:
    Leather furnitureUpholstered furnitureDog bedsOutdoor dog houseHuman bedsCarpets/rug
    Other:
    D. TREATMENT HISTORY


    Please list all medications your pet has been on during the past 12 months (please also include pet-store bought supplements). Also list duration of each treatment and whether it appeared to help your pet or not.
    Oral Medications (Pills, Capsules, Liquids, Tablets)
    Topical Medications (Medicated Shampoos, Creams, Ointments, Lotions, Sprays)
    Ear (Aural) Medications (Drops, Flushes, Ointments)
    Ophthalmic (Eye) Medications
    Did your pet have a negative/adverse reaction to any of the above medications? If yes, please list:

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