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Feline Allergy Questionnaire

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 Feline Allergy Questionnaire in PDF format   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 cats 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 cats “skin” please include paws and ears in your consideration to your answer. ALLERGY QUESTIONNAIRE PART “A” A) GENERAL *Indicates mandatory field Owner Name* Phone* Email* Clients Name* Pets Name* Breed* Age* Sex* Select Male Female Male/Neutered Female/Spayed Age or Date when you aquired pet Has the cat moved residence Yes No If YES when If YES was it Local From Another Province   International   From To Any other pets in household Yes No If YES please list Any negative interactions with other animals (inside or outside) Yes No Any other pets or people with skin problems Yes No If YES please describe Cats normal temperament-describe B) SYMPTOMS Describe problem Approximate date when problem first started If problem continuous for over a year, did it start off as seasonal Yes No When --------------- Choose one ---------------- Spring (Mar, Apr, May) Summer (Jun, July, Aug) Fall (Sept, Oct, Nov) Winter (Dec, Jan, Feb) Are symptoms getting worse Yes No When did it start to get worse Where problem started- check all that apply Face Eyes Ears Neck Back Tail Rump Armpits Front Legs Back legs Thighs Front Paws Back Paws Chest Abdomen Groin Nails             What did the problem look like initially Normal Skin, just “itch” Pimples Draining wounds   Hair Loss Redness       Rash Scabs/Crusts       Has problem spread Yes No If so when/where: C) ENVIRONMENT Percent of time spent Indoors(%) Outdoors(%) D) RESPIRATORY SYMPTOMS Cough Sneezing Runny Eyes Laboured Breathing E) 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) Number of bowel movements your pet has per day 1 2 3 4 5 6 F) DRUG HISTORY (check all that apply) Antihistamines (ie: Benadryl…) When Did it help?  When was it stopped? 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 If Yes, what were the symptoms? Vomiting Diarrhea Skin got worse Severe Itching         Other         G) FOOD HISTORY List pet foods from most current to oldest (bring ingredient label or write down on separate sheet first 5 ingredients) 1. Select Can Dry Both Can & Dry How long has it been fed for? 2. Select Can Dry Both Can & Dry How long has it been fed for? 3. Select Can Dry Both Can & Dry How long has it been fed for? 4. Select Can Dry Both Can & Dry How long has it been fed for? 5. Select Can Dry Both Can & Dry 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 Will your cat eat canned or wet foods? Yes No     Please wait...

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