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Dermatology Questionnaire: ITCH
Owner Name
First Name
Last Name
Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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1926
1925
1924
1923
1922
1921
1920
Year
Pet Information
Pet Name
Species
Breed
Age
What symptoms is your pet experiencing?
Rows
No
Mild
Moderate
Severe
1. Itching
2. Losing hair
3. Scratching or shaking head (possible ear infection)
4. Gaining weight
5. New or existing lumps or bumps
6. Fleas
7. Ticks
On a scale of 1 - 10, (10 being the itchiest) how itchy is your dog?
1-10
Total:
0
/
10
How long has your dog or cat been itchy?
How old were they when they started itching?
Is your pet itchy all year or is it seasonal?
Where does your pet itch the most?
Around the muzzle
Ears
Eyes
Neck
Front feet
Back feet
Armpits
Groin area
Belly
Legs
Back by their tail
Other
Is your pet on flea or tick preventative? If so, what kind and when was it last given?
When was the last time you gave your pet a bath? What kind of shampoo did you use?
Please do not bathe your dog within 3 days of appointment
What kind of food do you feed your pet? What kind of treats do you give? Any table food? Supplements?
What kind of treatments have you tried so far? Did it work?
Rows
What was used?
When was it given/used?
Did it help?
If so, how much?
Treatment 1
Yes
No
A little
A couple days
A week or two
A month
Longer than a month
Treatment 2
Yes
No
A little
A couple days
A week or two
A month
Longer than a month
Treatment 3
Yes
No
A little
A couple days
A week or two
A month
Longer than a month
Treatment 4
Yes
No
A little
A couple days
A week or two
A month
Longer than a month
Treatment 5
Yes
No
A little
A couple days
A week or two
A month
Longer than a month
Treatment 6
Yes
No
A little
A couple days
A week or two
A month
Longer than a month
Treatment 7
Yes
No
A little
A couple days
A week or two
A month
Longer than a month
Submit
Should be Empty: