Increase In Symptoms Questionnaire
Spectrum Veterinary Lab Number:
*
EX. 210003944
Pet's Name:
Dr.'s Name:
Clinic Name:
Phone Number:
-
Area Code
Phone Number
How do you wish to receive schedule suggestions?
Email
Fax
Fax Number:
-
Area Code
Fax Number
Email Address:
example@example.com
Patient Species:
Canine
Feline
Equine
Animal Is On:
*
Subcutaneous Injections
Sublingual Oral Spray
Is it a single or double treatment set?
Single
Double
Date of Last Injection?
*
-
Month
-
Day
Year
Date
Date of Last Spray?
*
-
Month
-
Day
Year
Date
Dosage Amount:
*
mL
What Vial is the Animal Currently On?
*
Vial "A" (Green)
Vial "B" (Blue)
Vial "C" (Red)
Current Conditions and Symptoms? (Check all that Apply):
Itchy
Diarrhea
Lethargy
Vomiting
Hives
Redness
Oily Skin
Current Conditions and Symptoms? (Check all that Apply):
Itchy Skin
Redness/Inflammation
Hair loss
Urticaria/Hives
Runny Eyes/Nose
Wheezing/Coughing
Labored Breathing
Lethargy
Other
Describe the Patient's Current Condition and Symptoms:
What happens with the symptoms 48 hours post injection?
Symptoms Increase
Symptoms Decrease
No Visible Change
Additional information:
Is the Animal on relief medications?
Oral Prednisone
Injectable Prednisone
Antihistamines
Apoquel
Cytopoint
Other
Is the animal on medication to control allergy symptoms or medication for other unrelated conditions?
What type of insect/fly control is used?
Topicals
Sprays
Barriers
Wipes
Sheets
Masks
Traps
Roll-On
Other
What type of bedding is used?
How much of the day is the horse stalled?
How much of the day is the horse turned out?
Are the symptoms seasonal?
Yes
No
Not Sure
What season are the symptoms the worst?
Winter
Spring
Summer
Fall
What does the patient's diet consist of? (Please be specific)
Does the horse travel outside of his normal environment?
Yes, rarely
Yes, often
No, never
Does travel effect the horses allergy symptoms?
How much time does the patient spend indoors?
How much time does the patient spend outdoors?
How much time does the patient spend in the barn?
Submit
Should be Empty: