|Pet Name (required)
|E-Mail Address (required) :
|Date of Appointment
|What skin/ear problems does your pet have? Check all that apply (required)
Itching (includes scratching, chewing, licking, rubbing, and biting)
|What age was your pet when the problems began?
|Which of the following best describes the progression of your pet's skin problem?
I first notice itching (such as scratching, biting, chewing, licking, or rubbing) prior to any skin lesions
I only notice itching (such as scratching, biting, chewing, licking, or rubbing) with no lesions
I notice a skin rash/lesions or hair loss followed by itching
I only notice skin rash/lesions or hair loss without any itching
None of the above apply to my pet
|Rate itch level on a scale of 1 to 10 (1 = minimal, 10 = obsessive/constant)
|Please check all of your pet's affected areas
|List the top three most affected areas on your pet's body and/or where your pet is the itchiest
|Is the problem seasonal or year round?
|If seasonal, in which season does the problem occur?
|If year round, do the signs worsen during a particular season?
|Do you have any other pets? Check all that apply
Other Small Mammals (Mice/Rats/Hamsters/Gerbils)
Pet Bird (parrot, parakeet, cockatiel)
Can I count my children as pets since they don't clean up after themselves?
Can I count my spouse as a pet since he/she doesn't clean up after themself?
|Do any of the other pets have skin problems/itching? If so, please describe
|Do any people in the home have skin lesions? If yes, please describe
|What is your pet's current diet, include treats given
|Has your pet ever been on a prescription diet or home cooked diet to rule out food allergies?
|If you have done a food trial to rule out food allergy, which brand/diet did you use and for how long?
|How many bowel movements does you pet have per day? Are there any other intestinal symptoms that your pet regulary has (soft stools, diarrhea, vomiting, flatulence)?
|What percentage of time does your pet spend indoors vs. outdoors?
|What is the primary indoor flooring surface?
|Do you have wool carpeting?
|Does anyone in the household smoke?
|Do you live near farm land such as corn or hay fields? Please describe and indicate how close they are to your home.
|Does your pet have any other signs of illness such as coughing/sneezing, vomiting, diarrhea, decreased appetite, excessive drinking or urination, limping, weight loss or weight gain?
|If so, please describe
|What is your pet's flea/tick prevention? How often is it applied/administered?
Treatment History: Has your pet received the following medications?
|Antihistamines (Benadryl, Hydroxyzine, Zyrtec, other)? If so, did they help?
|Steroids (Prednisone, Temaril P, Steroid/cortisone shots)? Did they help?
|Antibiotics (Cephalexin, Simplicef, Clavamox, Baytril, Zeniquin)? Did they help?
|Topical treatments such as shampoos, sprays, creams, ointments, ear treatments? Please include names. Did they help?
|Allergy shots or drops? Did they help?
|Atopica (cyclosporine)? Did it help?
|Apoquel? Did it help?
|Cytopoint? Did it help?
|Please list the current oral medications that your pet is receiving including milligrams and frequency of administration
|Please list the current topical medications that you are using on your pet including topical ear treatments, shampoos, lotions, sprays etc and frequency of use.
|Is there anything else you would like us to know about your pet and/or your pets skin/ear problems?
|What is your primary care veterinarian's name and/or veterinary practice name?