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I am having a difficult time grieving my loss. What support resources are there?
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What is making my pet so itchy!?
Owner Info
Name
First
Last
Email
Pet’s Info
Name
Indicate if and how your dog’s itching has affected his or her behavior and relationship with you. Check all that apply.
Hair loss
Foul odor
Inflammation or redness
Itching and scratching
Otitis (ear infections)
Licking and or chewing
Skin lesions (sores)
Changes in skin (reddish-brown stains, discolorations and/or areas that are thick and leathery)
Has your pet ever had ear problems?
Yes
No
Does your pet have any chronic gastrointestinal signs such as diarrhea or vomiting?
Yes
No
On a scale of 0 to 10 rank the severity of your pet’s symptoms.
0 being no symptoms and 10 being severe.
Severity of Condition Overall
0
1
2
3
4
5
6
7
8
9
10
Severity of Skin Lesions
0
1
2
3
4
5
6
7
8
9
10
Severity of scratching, licking or chewing
0
1
2
3
4
5
6
7
8
9
10
Is this the first time your dog has experienced these symptoms?
Yes
No
At what age did the symptoms first occur?
<1yr
1-3yrs
4-7 yrs
7+ yrs
How long have the current symptoms been going on?
Did the itch start gradually and over time become worse?
Yes
No
Did the itch come on suddenly without warning?
Yes
No
Was there a “rash” first or itching first? Or was it simultaneous?
Rash first
Itch first
Simultaneous
N/A
Is your pet on flea/tick medication?
Yes
No
What product is your pet on?
When was the last time you administered the parasite medication?
Are there other pets in your household?
Yes
No
Do these pets have the same symptoms?
Yes
No
Do you board your dog or take him or her to obedience school, training or groomers?
Yes
No
When was the last time you took your dog?
Have you taken your dog on a trip to another location, outside of the local area?
Yes
No
Please indicate when and which location:
Have you recently moved?
Yes
No
Have you used any new shampoos or topical skin treatments recently?
Yes
No
What pet food are you feeding your dog?
Do you feed the same food all the time or provide a variety?
Always the same
Variety
Have you changed your pet’s food recently?
Yes
No
Do you give your pet packaged treats, including rawhides?
Yes
No
Do you feed your pet “human” food?
Yes
No
Indicate if and how your dog’s itching has affected his or her behavior and relationship with you. Check all that apply.
Sleeps through the night
Always
Usually
Occasionally
Never
Activity Level
Inactive
Much less active
Somewhat less active
No change
Social Behaviour
Unsocial
A lot less social
Somewhat less social
No change
Relationship Changes
Fewer walks
No longer sleeps in bed or same room
Interacts less with family
Is your pet currently on any medications, supplements or herbal remedies?
Yes
No
Please provide product names and how often you give or apply the product.
Indicate previous treatments administered to your pet
Steroids
Shampoos
Sprays
Ointments
Antibiotics
Hypoallergenic food from vet clinic
Hypoallergenic food from pet store
Essential fatty acids
Antihistamines
Immunotherapy
check all that apply
Please indicate if you have any specific questions and/or concerns
About Us
Join Our Team
Location & Hours
Meet Our Team
History of Shannondale Farm
What’s happening at Shannondale
Memorials
Forms
Links
Clients
Take A Tour
Pet Insurance
Survey Form
Request an Appointment
Services
Dental Healthcare
Euthanasia and Aftercare
How do I setup the appointment?
What happens during the appointment?
What actually happens when my pet is put to sleep?
Will the procedure be painful for my pet?
What are my options for aftercare?
I am having a difficult time grieving my loss. What support resources are there?
Anesthesia and Patient Monitoring
Medical Services
Preventive Services
Surgical Services
Wellness and Vaccination Programs
Additional Services
Emergency Information
Pet Health
Educational Articles
How-To Videos
Pet Health Checker
News
Pet Portal
Contact Us
