Pet Allergy Information Form

Name *

First Name

Last Name

Phone

(###)

###

####

Does your pet do any of the following?

Select all that apply

Scratch

Chew

Bite

Rub

Lick

Other (specify below)

If yes, where?

Select all that apply

Ears

Face

Feet

Body

Tail

Rump

Legs

Which of the following started first?

Choose One

Itching / Scratching

Hair Loss / Rash

Where is your pet primarily?

Choose One

Indoors

Outdoors

Percentage of time spent indoors (if applicable)?

Choose One

1-25%

26-50%

51-75%

76-100%

Percentage of time spent outdoors (if applicable)

Choose One

1-25%

26-50%

51-75%

76-100%

Describe your pet's outdoor environment (if applicable)

Select all that apply

Rural

Wooden

Suburban

Urban

Near Water

What other pets are in your household?

Cat

Dog

Bird

Ferret

Rabbit

Small Rodents

Other (specify below)

Do any other household pets have skin conditions?

Choose One

No

Yes

How often is your pet bathed?

Never

Irregularly

Weekly

Monthly

Shampoo type used?

Select all that apply

Anti-itch

Antibacterial

Anti-fungal

Hypoalleregenic

Food Type

Select all that apply

Homemade

Hypoallergenic

Commercial

Perscription

Raw

Are they ever fed from the dinner table (human food)?

Select One

No

Yes

What treats do they get?

Select all that apply

Biscuits

Rawhide

Chewies

Bones

Flea Controlled?

Select One

No

Yes

Are all household pets on preventatives?

Select One

No

Yes

Has a food trial been performed?

Select One

No

Yes

Was the diet strictly adhered to?

Select One

No

Yes

During which season(s) are symptoms present?

Select all that apply

Summer

Fall

Winter

Spring

Is Malassezia a problem for the pet?

Select One

No

Yes

Were skin scrapings performed?

Select One

No

Yes

If yes, were scrapings positive for Sarcoptes?

Select One

No

Yes

Was pet treated for Sarcoptes?

Choose One

No

Yes

How many times has pet been treated for pyoderma?

Select One

Never / Rarely (once per year)

Occasionally (2-3 times per year)

What is the steroid response?

Select One

No Response

Temporary / Mild Response

Excellent Response

Were other treatments employed?

Select One

No

Yes

What was the response to alternate treatment?

Select One

No Response

Temporary / Mild Response

Excellent Response

Pruitis?

Select One

Present

Absent

Seasonal?

Select One

No

Yes

Worse:

Select One

Spring/Summer

Fall/Winter