Initial Questionnaure – Feline Dermatology

Important notes:

itchiness in pets includes the following: Itching, Scratching, Excessive Grooming, Chewing, Biting, Rubbing, Scooting (rubbing of hind end), and Head Shaking.
This questionnaire is intended to prepare yourself and Our Vet Staff for your appointment. Please send back the filled form to the GHSVet at least 1 days before your scheduled appointment.
Ears and paws are common areas affected by allergies. Some cats may experience ear irritation or excessive paw licking/biting before other parts of the skin show symptoms. When discussing your cat’s skin concerns, please consider the paws and ears as well.
If you do not know the answer to a question or do not understand the question please leave the answer blank. DO NOT guess.

Owner Name

Phone Number

Pet Name

Sex

Age or Date you acquired your pet

Have you recently moved with your pet?

Yes No International

If YES, please provide details including the timing of the move

Has your pet had any allergy testing done previously?

Yes No

If YES, where and when?

Have you noted a loss in your pet’s weight?

Yes No

Have you noted weight gain in your pet?

Yes No

Have there been any changes in your pet’s activity levels?

Yes No

Have you noticed any changes in your pet’s thirst or urination habits?

Yes No

Has your pet received treatments for intestinal problems/upset in the past?

Yes No

Does your cat vomit hairballs

Yes No

IF yes, How Frequently?

How many bowel movements does your cat have per day?

How many bowel movements does your pet have per day?

Does your pet have any non-dermatology related health conditions or illnesses? If so please provide details:

Approximate date or age of when your pet’s symptoms FIRST started

If problem has been continuous for over a year, did it start off as seasonal? (yes/no)

How itchy is your dog currently on a scale of 1 to 10? (Please use the Canine and Cat Pruritus Analog Scale to help in assessment of your pets itch score)

Are symptoms getting worse? (yes/no)

Is there a time when your pet is more or less itchy? (yes/no)

If yes, please provide more details on variations in itch:

Was the “itchiness” the first symptom you noticed? (yes/no)

How much time does your pet spend: (Indoors %/ Outdoors %)

Type of flooring in your residence: (Carpeted Flooring %/ Tile-wood-cement %)

Oral Medications (Pills, Capsules, Liquids, Tablets)?

Topical Medications (Medicated Shampoos, Creams, Ointments, Lotions, Sprays)?

Ear (Aural) Medications (Drops, Flushes, Ointments)?

Ophthalmic (Eye) Medications?

Did your pet have a negative/adverse reaction to any of the above medications? If yes, please list:?

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