info@highlandsveterinaryhospital.com.au
(02) 4872 1144
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Skin & Allergies Questionnaire
Today's Date:
Owner's Details
Name:
First Name:
Last Name:
Email:
Phone:
Pet's Details
Pet's Name:
Species of Pet:
Breed of Pet:
Pet's Sex:
Male
Female
Date of Birth:
Pet's Age:
Is the pet desexed?:
Yes
No
What is your pet’s main problem today? Please check all that apply and add details as needed.:
Dandruff
Dry skin
Hair loss
Itching
Odor
Oily Skin
Rash
Redness
Other
Has your pet ever been treated for this problem before?:
Yes
No
Approximate month and year:
Medications:
Other Treatments:
Results of Medications and Other Treatments:
How old was your pet when you first noticed this problem?:
What was the very first sign of this problem?:
I'm not sure
Itching
Something other than itching
Where on your pet’s body did the problem begin? Please check all that apply and add details as needed.:
I'm not sure
Back
Chest
Ears
Eyes
Groin
Legs
Neck
Nose
Paws
Rump
Stomach
Tail
Something Else
Has it spread?:
No
I'm not sure
Yes
Does it look different today?:
No
I'm not sure
Yes
My pet scratches, rubs, chews, licks, or bites parts of his/her body. Please check all that apply and add details as needed.:
Abdomen
Axilla (arm pit)
Back
Legs
Chest
Eyes
Groin
Muzzle
Neck
Nose
Paws
Rump
Tail
Somewhere Else
None of the Above
My pet’s symptoms seem to get BETTER sometimes. Please check all that apply and add details as needed.:
In the Spring
In the Fall
In the Summer
In the Winter
At Night
In the Morning
After This Situation or Event
At a Particular Time of Day
After Eating
After Taking Medication
In the House
Outside
None of the Above
My pet also has some other problems. Please check all that apply and add details as needed:
Coughing
Sneezing
Runny Nose
Runny Eyes
Vomiting
Diarrhea
Poor Appetite
Excessive Appetite
Head Shaking
None of the Above
Has your pet been out of his or her usual environment recently (vacation, play date, day-care, visit to family or friends, kennel, pet-sitter, and so on)?:
Yes
No
Please explain::
What does your pet eat? Please tell us frequency of meals, amounts, and brands if possible:
Canned Food
Dry Food
Treats
Human Food
Other
Other Option
Has your pet been neutered?:
No
I'm not sure
Yes
How much time does your pet spend in the house?:
Never comes in the house.
Stays in the house almost all the time.
Only comes in at night.
Other
Other Option
How much time does your pet spend outside?:
Never comes in the house.
Stays in the house almost all the time.
Only comes in at night.
Other
Other Option
Do you (or someone else) bathe/groom your pet at home?:
No
Yes
Do you (or someone else) bathe/groom your pet somewhere else?:
No
I'm not sure
Yes, now
Yes, In the past
Does your pet have any other illnesses?:
No
I'm not sure
Yes, now
Yes, In the past
Do you have any other indoor animals?:
No
Yes
Do you have any other outdoor animals?:
No
Yes
Do any of your other outdoor animals have skin problems?:
No
Yes
Do any people in your house have skin problems?:
No
Yes
Does your pet have fleas?:
No, not now
Yes, now
Yes, in the past
Do you use flea-control products outside your house? That is, on your lawn, patio, deck, shrubs, and so on. This question does NOT apply to products used directly on your animal(s):
No
Yes
If you do use flea-control products (inside, outside, or on your animals) when do you use them? Please check all that apply and add details as needed:
I don’t use any flea-control products
Summer
Winter
Spring
Fall
Other
Other Option
Email Address
HIGHlands Locations We Serve
Braemar
Mittagong
Colo Vale
Alpine
Aylmerton
Renwick
Welby
Bowral
Moss Vale
Hill Top
Yerrinbool
Burradoo
Berrima
Contact Details
66 Old Hume Hwy
Braemar NSW 2575, Australia
(02) 4872 1144
info@highlandsveterinaryhospital.com.au
Hours
Mon - Fri: 8:15 am to 5:00 pm
Sat: 8:15 am to 12:00 pm
Sun: Closed
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