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)
    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)
    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.