Animal Dermatology Clinic of BC

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Certified Specialist in Skin, Ears, Hair, Nails and Allergies

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
Download PDF
 
Fax form to (604) 558-3379
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*
Age or Date when you aquired pet
Has the cat moved residence
Yes No
Any other pets in household
Yes No
Any negative interactions with other animals (inside or outside)
Yes No
Any other pets or people with skin problems
Yes No
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
Are symptoms getting worse
Yes No
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

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

G) FOOD HISTORY

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
Will your cat eat canned or wet foods?
Yes No
 
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