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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