Allergy/Itching Questionnaire Name First Last PhoneEmail Please check any of the boxes that describe your pet Hair loss Foul Odor Redness/Inflammation Changes in Skin (reddish brown stains) Skin Lesions (Sores) Licking/Chewing Otitis (Ear Infections) Itching/ScratchingWhat areas of the body are affected?How bad is your pet's scratching or itching?12345678910Is the itching or scratching a continual year-round problem, or is it a seasonal problem?Year-RoundSeasonalHow long have the symptoms been occurring?How much time does your pet spend indoors/outdoorsWhat type of flea-tick preventative do you use for your pet? (Check all that apply) Revolution Frontline Advantix Sentinel Comfortis OtherHow often do you apply it?Are all pets in household treated for fleas?YesNoWhat is your pet's diet? State the brand and type of food.What type of treats do you give your pet?Does your pet get any table food?YesNoPlease write the name of the shampoo(s) you use.How often do you bathe your pet?Do any other pets or people have the same symptoms?YesNoYour pet's activity levelNo ChangeSomewhat less activeMuch less activeCheck previous treatments administered to your pet: Steroid/Prednisone Antihistamines Prescription Shampoo Immunotherapy Sprays Fatty Acids Ointments Antibiotics Hypoallergenic DietNEXT STEPS: COMPREHENSIVE PHYSICAL EXAMINATION AND LABORATORY TESTING: Ear Swab-to identify underlying infection deep in ear canal. Skin Scrape/Hair Pluck-To detect scabies or demodex mites. Skin Cytology/Tape Prep-to detect presence of yeast and/or bacteria.NameThis field is for validation purposes and should be left unchanged. Like Us On FacebookAppointmentsWe will do our best to accommodate your busy schedule. Please schedule an appointment today!Request AppointmentGet Directions
