Skin & Allergies Questionnaire

We are looking forward to seeing you and your pet. In order to help us understand your pet’s Skin/Allergy issues, please complete this questionnaire prior to your appointment. Your answers will help us give your pet the best care possible.

Please note: any fields with * are required.

Today's Date(Required)

DD slash MM slash YYYY

Owner's Details

Name(Required)

First Last

Email(Required)

Owner's Phone Number(Required)

Pet's Details

Pet's Name(Required)

Species of Pet(Required)

Breed of Pet(Required)

Pet's Sex

Male

Female

Pet's Age/Date of Birth(Required)

Is the pet desexed?

Yes

What is your pet’s main problem today? Please check all that apply and add details as needed.(Required)

Dandruff

Dry skin

Hair loss

Itching

Odor

Oily Skin

Rash

Redness

Other

If other, please describe

Has your pet ever been treated for this problem before?

Yes

Approximate month and year:

Medications:

Other Treatments:

Results of Medications and Other Treatments:

How old was your pet when you first noticed this problem?(Required)

What was the very first sign of this problem?

I'm not sure

Itching

Something other than itching

If something else, please describe.

Where on your pet’s body did the problem begin? Please check all that apply and add details as needed.

I'm not sure

Back

Chest

Ears

Eyes

Groin

Legs

Neck

Nose

Paws

Rump

Stomach

Tail

Something Else

If Back, please describe:

If Chest, please describe:

If Ears, please describe:

If Eyes, please describe:

If Groin, please describe:

If Legs, please describe:

If Neck, please describe:

If Nose, please describe:

If Paws, please describe:

If Rump, please describe:

If Stomach, please describe:

If Tail, please describe:

If something else, please describe:

Has it spread?(Required)

I'm not sure

Yes

If yes, please explain:

Does it look different today?(Required)

I'm not sure

Yes

If yes, please explain:

My pet scratches, rubs, chews, licks, or bites parts of his/her body. Please check all that apply and add details as needed.(Required)

Abdomen

Axilla (arm pit)

Back

Legs

Chest

Eyes

Groin

Muzzle

Neck

Nose

Paws

Rump

Tail

Somewhere Else

None of the Above

If Abdomen, please describe:

If Axilla (arm pit), please describe:

If Back, please describe:

If Legs, please describe:

If Chest, please describe:

If Eyes, please describe:

If Groin, please describe:

If Muzzle, please describe:

If Neck, please describe:

If Nose, please describe:

If Paws, please describe:

If Rump, please describe:

If Tail, please describe:

If somewhere else, please describe:

My pet’s symptoms seem to get BETTER sometimes. Please check all that apply and add details as needed.(Required)

In the Spring

In the Fall

In the Summer

In the Winter

At Night

In the Morning

After This Situation or Event

At a Particular Time of Day

After Eating

After Taking Medication

In the House

Outside

None of the Above

In the Spring - please describe.

In the Fall - please describe.

In the Summer - please describe.

In the Winter - please describe.

At Night - please describe.

In the Morning - please describe.

After This Situation or Event - please describe.

At a Particular Time of Day - please describe.

After Taking Medication - please describe.

In the House - please describe.

Outside - please describe.

My pet also has some other problems. Please check all that apply and add details as needed.(Required)

Coughing

Sneezing

Runny Nose

Runny Eyes

Vomiting

Diarrhea

Poor Appetite

Excessive Appetite

Head Shaking

None of the Above

Coughing - please describe.

Sneezing - please describe.

Runny Nose - please describe.

Runny Eyes - please describe.

Vomiting - please describe.

Diarrhea - please describe.

Poor Appetite - please describe.

Excessive Appetite - please describe.

Head Shaking - please describe.

Has your pet been out of his or her usual environment recently (vacation, play date, day-care, visit to family or friends, kennel, pet-sitter, and so on)?(Required)

Yes

Please explain:

What does your pet eat? Please tell us frequency of meals, amounts, and brands if possible.(Required)

Canned Food

Dry Food

Treats

Human Food

Other

Canned Food - please describe.

Dry Food - please describe.

Treats - please describe.

Human Food - please describe.

Other - please describe.

Has your pet been neutered?(Required)

I'm not sure

Yes

What age was your pet neutered?

How much time does your pet spend in the house?(Required)

Never comes in the house.

Stays in the house almost all the time.

Only comes in at night.

Other

If Other, please explain.

How much time does your pet spend outside?(Required)

Never goes outside.

Stays outside almost all the time.

Only goes out at night.

Other

If Other, please explain.

Do you (or someone else) bathe/groom your pet at home?(Required)

Yes

Frequency and products when grooming

Do you (or someone else) bathe/groom your pet somewhere else?(Required)

I'm not sure

Yes, now

Yes, in the past

If now, please describe

If in the past, please describe

Does your pet have any other illnesses?

I'm not sure

Yes, now

Yes, in the past

If now, please describe

If in the past, please describe

Do you have any other indoor animals?(Required)

Yes

Please describe

Do you have any other outdoor animals?(Required)

Yes

Please describe

Do any of your other outdoor animals have skin problems?(Required)

Yes

Please describe

Do any people in your house have skin problems?(Required)

Yes

Please describe

Does your pet have fleas?(Required)

No, not now

Yes, now

Yes, in the past

I saw the last flea (date):

I used the following products:

Do you use flea-control products outside your house? That is, on your lawn, patio, deck, shrubs, and so on. This question does NOT apply to products used directly on your animal(s).(Required)

Yes

Brand and frequency of use:

If you do use flea-control products (inside, outside, or on your animals) when do you use them? Please check all that apply and add details as needed.

I don’t use any flea-control products

Summer

Winter

Spring

Fall

Other

If other, please explain

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Skin & Allergies Questionnaire

Owner's Details

Pet's Details

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