Initial Questionnaire - Feline Dermatology

IMPORTANT NOTES:

1) Itchiness in pets includes the following: Itching, Scratching, Excessive Grooming, 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 a history of ear infections or paw licking/biting before other areas of skin become involved.For questions relating to your cats “skin” please include paws 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
Does your cat vomit hairballs?
YesNo
If YES, how frequently?
How many bowel movements does your cat have per day?
Has your pet had/or currently have any of the following symptoms?
VomitingGas/FlatulenceDiarrheaSoft StoolsBad BreathInappetanceBorborygmus (rumbling or gurgling intestinal sounds)None
Have you noticed any of the following symptoms in your pet?
Runny EyesRedness of EyesRunny NoseSneezingCoughingTirednessReverse 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 cat currently on a scale of 0 to 4? (Please use the Feline Pruritus Analog Scale to help in assessment of your cat’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
Do you feel like your cat over-grooms him/her self?
YesNo
C) INFORMATION ON ENVIRONMENT
How much time does your pet spend:
%
%
Type of flooring in your residence:
%
%
Where does your cat sleep? Please check all that apply:
Leather furnitureUpholstered furnitureHuman bedsCarpets/rugScratching postCat House
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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