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Initial Questionnaire - Canine and Feline Dermatology


IMPORTANT NOTES
  • Itchiness in pets includes the following: Itching, Scratching, Licking, Chewing, Biting, Rubbing, Scooting (rubbing of hind end), and Head Shaking.
  • 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 dogs “skin” please include paws and ears in consideration to your answer.
  • This questionnaire is intended to prepare yourself and Dr. MacMillan and Dr. Pettersen for your appointment. Please send back the filled out questionnaire to the hospital at least 24 hours before your scheduled appointment.
  • If you do not know the answer to a question or do not understand the question please leave the answer blank.

    GENERAL INFORMATION

    SYSTEMIC (GENERAL) HISTORY
    INFORMATION ON DERMATOLOGIC SYMPTOMS
    How itchy is your dog currently on a scale of 1 to 10?
    (Please use the 
    Canine Pruritus Analog Scale below to help in assessment of your dog's itch score)
    Picture
    How itchy is your cat currently on a scale of 1 to 10?
    (Please use the Feline 
    Pruritus Analog Scale below to help in assessment of your cat's itch score)
    Picture
    INFORMATION ON ENVIRONMENT
    TREATMENT HISTORY ​
    DIET
    Thank you for taking the time to provide us with feedback regarding your pet’s history. If you would like to offer additional feedback, please provide it in the following space.

    DIAGNOSTICS

    Often, to get the best diagnostic results, samples collected from the ears and skin and examined under the microscope help us determine what the infection is and what the best treatment plan would be for your pet. 
Submit
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  • Home
  • Who We Are
  • Services
  • Tour
  • New Puppies and Kittens
  • Client and Patient Forms
  • What To Expect
    • COHAT Dental Procedure
    • Cranial Cruciate Rupture - TPLO Surgery
    • Orchiectomy - Feline Neuter
    • Orchiectomy - Canine Neuter
    • Ovariohysterectomy - Canine and Feline Spay
  • Newsletters
    • July 2021
    • August 2021
    • Fall 2021
    • Holiday Newsletter 2021
    • Dental Month 2022
    • Farley Foundation Announcement
    • January 2022 Newsletter
    • February 2022 Newsletter
    • March 2022 Newsletter
    • April 2022 Newsletter
    • May 2022 Newsletter
    • July 2022 Newsletter
    • August 2022 Newsletter
    • September 2022 Newsletter
    • Glendale Fall Newsletter
    • Glendale November Newsletter 2022
    • Glendale January Newsletter 2023
  • Pet Insurance
  • Careers at Glendale
    • Glendale Culture
  • National Wildlife Centre
  • Pet Health Education Articles
  • A Final Note