Additional Patient History: Itchy Dogs

Client Name:* This field is required.

Patient Name:* This field is required.

Please check any that describe your dog:* This field is required.

Hair Loss

Foul Odor

Inflammation or Redness

Itching/Scratching

Ear Infections

Licking or Chewing Feet

Licking or Chewing Other Areas

Skin lesions (sores)

Changes in skin (reddish brown stains, discolorations, areas that are thick/leathery)

Other

Please indicate where on your dog's body the above issues have been noted:* This field is required.

Has your dog ever had ear problems?* This field is required.

Yes

Does your dog have any chronic gastrointestinal signs like diarrhea or vomiting?* This field is required.

Yes

Severity of your dog's OVERALL CONDITION:

Mild

Severe

Severity of your dog's SKIN LESIONS:

Severity of your dog's SCRATCHING/LICKING/CHEWING:

Is this the first time your dog has experienced these symptoms?* This field is required.

Yes

At what age did the symptoms first occur?* This field is required.

Less than 1 year

1-3 years

4-7 years

7+ years

Have symptoms occurred around the same time of year each time?* This field is required.

Yes

Approximate time of year symptoms occur:* This field is required.

How long have the current symptoms been going on?* This field is required.

Did the itch start gradually and over time become worse?* This field is required.

Yes

Did the itch come on suddenly without warning?* This field is required.

Yes

Was there a rash first or itching first? Or simultaneous?* This field is required.

Rash first

Itch first

Simultaneous

Is your dog receiving a flea and tick preventative?* This field is required.

Yes

What product are you administering?* This field is required.

What months do you administer flea and tick preventative?* This field is required.

Year Round

Summer months only

When I remember

Other

When was your last dose of flea and tick prevention given?* This field is required.

What most accurately represents your pet's lifestyle* This field is required.

Inside exclusively (uses potty pads for eliminations)

Outside exclusively

Inside and Outside

If your pet has access to the outdoors, is it:* This field is required.

Outside supervised on a leash

Outside unsupervised - in a fenced area

Outside unsupervised - free roaming without fence

Pet never leaves our home

Are there other pets in your household?* This field is required.

Yes

Do these pets have the same symptoms?* This field is required.

Yes

If these pets are cats, do they go outside?* This field is required.

Yes

Do you board your dog, take it to obedience class/training, or a groomer?* This field is required.

Yes

When was the last time you took your dog?

Have you taken your dog on a trip to another location?* This field is required.

Yes

Please indicate when and where:

Have you recently moved?* This field is required.

Yes

Have you been to a new dog park or walking trail?* This field is required.

Yes

Have you used any new shampoo or topical skin treatments recently?* This field is required.

Yes

Are any humans in your household exhibiting signs?* This field is required.

Yes

What pet food are you feeding?* This field is required.

Do you feed the same food all the time or provide a variety?* This field is required.

Always same

Variety

Have you changed your dog's diet recently?* This field is required.

Yes

Do you give your dog packaged treats?* This field is required.

Yes

What human food does your dog regularly enjoy?* This field is required.

Does your pet sleep through the night?* This field is required.

Always

Usually

Occasionally

Never

Describe your pet's activity level:* This field is required.

Inactive

Much less active

Somewhat less active

No change

Describe your pet's social behavior:* This field is required.

Unsocial

A lot less social

Somewhat less social

No change

Note any relationship changes - Check ALL that apply:* This field is required.

Fewer walks

No longer sleeps in bed/same room

Interacts less with family

Other

Has your dog been treated for itching before?* This field is required.

Yes

Indicate previous treatments administered to your dog (Check ALL that apply):

Steroids

Shampoos

Sprays

Ointments

Antibiotics

Hypoallergenic food

Essential fatty acids

Antihistamines

Immunotherapy

Cytopoint Injections

Apoquel

Other