Questionnaire

What is the main problem? ____________________________________
At what age was this condition first noticed? __________________________
Has there ever been any previous dermatitis? O  Yes O  No

Do the symptoms vary?
If the dermatitis has been present for some time are the symptoms worse in:
O spring?   O summer? O autumn?  O  winter?
Are the symptoms present all year round?   O Yes   O No
If yes, would there be a time of no symptoms at some stage?   O Yes O  No
What (if anything) causes a worsening of symptoms?____________________
What helps? ____________________________________________________

Home details:
Do you have any other pets  O Yes   O No
No and if so how many? __cats __dogs __birds __other
Do you know of any relative of this pet that has skin problems?   O Yes   O No
Does any human in the house have skin problems? O Yes   O No
Where does this pet sleep? ________________________________________
Have there been any other illnesses? ________________________________

Bathing and fleas:
Does bathing: O help  O worsen   O make no difference
How often do you prefer to bath your pet?   O weekly  O monthly  O rarely
When was the last time a flea was seen on this pet? ____ other pets? ____
What is the current flea treatment on this pet? ________________________
Is flea treatment used on other pets? ________________________________

Medication:
If previous medications have been used, do you know what they were? >  Yes >  No
If yes, were they: O shampoos O  rinses O  injections O  tablets O  ointments
Last tablet given (date): ______ Response: O  none O  some O  good
Last injection given: (date): ______ Response: >  none >  some >  good
Is your dog on heartworm tablets? O No   O  Yes:    O  daily    O  monthly

Diet:
What do you normally feed your pet?    O  cans    O  dry    O  table scraps    O  meat
If meat – which types? ____________________________________________
Any other foods? (eg., vitamins, toast, biscuits) ________________________
Have you ever fed a special diet?    O  No    O  Yes:
What? __________________ ______________________________________________________________

Symptoms?
Have any of the following been observed?
  O  sores    O  scabs    O  dandruff    O  hair loss    O  odor    O  hives    O  redness
  O  sweating    O  ear problems    O  watery eyes    O  heat    O  weight loss
  O  weight gain    O  vomiting    O  diarrhea    O  tiredness    O  depression
  O  increased appetite    O  increased thirst

Does your pet:
  O  rub at the face    O  lick or chew the paws    O  scratch at the sides
  O  roll on the back    O  bite at the tail area    O  lick the stomach area
  O  sneeze    O  snort    O  wheeze

Other? ______________________________
What do you think could be the cause of the problem? ________________________________________________________________________________