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.

Has your pet ever had ear problems?

Does your pet have any chronic gastrointestinal signs such as diarrhea or vomiting?

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

Severity of Skin Lesions

Severity of scratching, licking or chewing

Is this the first time your dog has experienced these symptoms?

At what age did the symptoms first occur?

How long have the current symptoms been going on?

Did the itch start gradually and over time become worse?

Did the itch come on suddenly without warning?

Was there a “rash” first or itching first? Or was it simultaneous?

Is your pet on flea/tick medication?

What product is your pet on?

When was the last time you administered the parasite medication?

Are there other pets in your household?

Do these pets have the same symptoms?

Do you board your dog or take him or her to obedience school, training or groomers?

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?

Please indicate when and which location:

Have you recently moved?

Have you used any new shampoos or topical skin treatments recently?

What pet food are you feeding your dog?

Do you feed the same food all the time or provide a variety?

Have you changed your pet’s food recently?

Do you give your pet packaged treats, including rawhides?

Do you feed your pet “human” food?

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?

Please provide product names and how often you give or apply the product.

Indicate previous treatments administered to your pet

check all that apply

Please indicate if you have any specific questions and/or concerns

Owner Info

Pet’s Info

On a scale of 0 to 10 rank the severity of your pet’s symptoms.

Indicate if and how your dog’s itching has affected his or her behavior and relationship with you. Check all that apply.

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