Animal Dermatology Clinic of BC

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Certified Specialist in Skin, Ear, Hair, Nail and Allergies

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    K9 Allergy Questionnaire PART "A"

    If you do not know the answer to a question or do not understand the question please leave the answer blank, DO NOT guess!
    Download Allergy Questionnaire in PDF format
    Download PDF
    		  
    Fax form to (604) 279-2040
    or fill out online version below
       

    IMPORTANT:
    Our definition of “Itchy” includes the following terms:

    		Itching
    Scratching
    Licking
    Chewing
    Biting
    Rubbing
       
    ALSO: Ears and paws are a common target for allergies. Some dogs may have a history of ear infections before paws or other areas of skin become involved. When we ask you a question relating to your dogs “skin” please include paws and ears in your consideration to your answer.
    ALLERGY QUESTIONNAIRE

    A) GENERAL
    *Indicates mandatory field
    Owner Name*
    Phone*
    Email*
    Clients Name*
    Pets Name*
    Breed*
    Age*
    Sex*
    Age or date when you aquired pet
    Has the dog moved residence
    Yes No
    Any other tests for allergies
    Yes No
      (If YES please provide us with a copy of the results)

    B) SYMPTOMS
    Approximate date when problem FIRST started
    If problem continuous for over a year, did it start off as seasonal
    Yes No
    When
    How itchy is your pet on a scale of 1-10 (10 being the worst possible)
    Are Symptoms getting worse
    Yes No
    When did it start to get worse
    Is there a time when the dog is less itchy
    Yes No
    If YES when
    Where does your pet “Itch” (refer back to definition) check all that apply
    Muzzle Eyes Ears Neck Back
    Tail Rump Armpits Front Legs Back Legs
    Thighs Front Paws Back Paws Chest Abdomen
    Groin Scoots Bum            
    Was the “itching” the first symptom/thing you noticed
    Yes No
    What did the problem look like initially
    Normal skin, just “itch” Pimples
    Hair Loss Redness
    Rash    
    Has problem spread
    Yes No
    If so when/where
    Have the ears been involved ie: infected, waxy +/- itchy
    Yes No

    C) INSIDE ENVIRONMENT
    Percent of time spent
    Indoors(%) Outdoors(%)
    Type of Flooring in your residence
    Carpets/Rugs(%) Tile/Wood(%)
    Any of them wool
    Yes No
    Where/when are symptoms at their worst
    Indoor Morning
    Outdoor Night
    No difference    
    Describe
    Which room does your pet sleep at night
    Bedroom Bathroom
    Family Room Kitchen
    Basement Garage
    Laundry Room Outside
    Other
    Where does your pet sleep at night
    On Bed Tile/Wood Floor
    Under Bed Carpet
    Beside Bed on floor Doggy Bed
    Couch/Chair Wool Blanket 
    Ulphostered Leather/Vinyl 
    Other
    Which room does your pet spend most of it’s time during the day
    Bedroom Bathroom
    Family Room Kitchen
    Basement Garage
    Laundry Room Outside
    Other
    Where does your pet spend most of it’s time during the day
    On Bed Tile/Wood Floor
    Under Bed Carpet
    Beside Bed on Floor Doggy Bed
    Couch/Chair Wool Blanket 
    Ulphostered Leather/Vinyl 
    Other

    D) ENVIRONMENT: Part II- Choose all that apply
    Wooded Area Decaying vegetation ie: mulches,leaves, rotting wood piles, compost
    Dog House Vegetable Garden
    Barns, Horse Manure Areas of water, ditches, ponds, lakes,river, ocean
           
    Damp House Water leaks, roof leaks
    Lots of Indoor Plants laundry room, hot water tank
    Type of trees in/around neighbourhood
    Outdoor surface
    Grass Deck Cement/tiles

    E) RESPIRATORY SYMPTOMS
    Cough Sneezing Runny eyes Laboured breathing Tires easily on walks

    F) G.I.T.
    Has your pet received treatment for stomach or intestinal problems/upsets
    Yes No
    Does your pet have or had any of the following
    Vomiting Diarrhea (loose/runny stool) Pass gas frequently
    Bad breath        
    Number of bowel movements your pet has per day
    1 2 3 4 5 6

    G) DRUG HISTORY (check all that apply)
     
    When Did it help? When was it stopped?
    Antihistamines (ie: Benadryl…)
    Yes No
    Cortisone (ie:prednisone, VanectylP)
    Yes No
    Cortisone Injections
    Yes No
    Atopica/Neoral (Cyclosporine)
    Yes No
    Antibiotics
    Yes No
    What kind
    Shampoo
    Yes No
    What kind
    Flea Control
    Yes No
    What kind
    Ear Meds
    Yes No
    What kind
    Eye Meds
    Yes No
    What kind
    Topical Meds
    Yes No
    What kind
    Were there any adverse reactions to any of the above?
    Yes No
    Vomiting Diarrhea Skin got worse
    Severe Itching        
    Other

    H) FOOD HISTORY (check all that apply)
    List pet foods from most current to oldest
    (bring ingredient label or write down on separate sheet first 5 ingredients)
    1. How long has it been fed for?  
    2. How long has it been fed for?  
    3. How long has it been fed for?  
    4. How long has it been fed for?  
    5. How long has it been fed for?  
    If there’s more than 5 diets please list them on separate sheet.
    Treats, list from most current to oldest (cookies, biscuits, chews, snacks etc)
    (bring ingredient label or write down on separate sheet first 5 ingredients)
    1. How often is it given?
    2. How often is it given?
    3. How often is it given?
    4. How often is it given?
    5. How often is it given?
    If there’s more than 5 please list them on separate sheet.
    Human Food, list foods from most current to oldest
    (bring ingredient label or write down on separate sheet first 5 ingredients)
    1. How often is it given?
    2. How often is it given?
    3. How often is it given?
    4. How often is it given?
    5. How often is it given?
    If there’s more than 5 please list them on separate sheet.
    When you changed diets/treats did you notice your pet getting better?
    Yes No
    Explain
    When you changed diets/treats did you notice your pet getting worse?
    Ear problems, skin problems, itching
    Yes No
    Explain
    OR
    No difference when you switch foods/treats
     

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