About you and your pet Owner's Name Owner's Address Phone number Email address (all information will be emailed to this address) Pet's name Dog /Cat/ Other Breed Age or date of birth Sex (male/male desexed/Female/Female desexed Skin Questions What is the main problem? How long as the problem been present? Days, weeks, months or years Is there a history of skin disease previous to this? Where on the body was first affected? What came first - the itch or the rash/hairloss? What time of year did the problem begin? Spring Summer Autumn Winter When is the skin problem present? All year round or Intermittent or Seasonal? What did the affected area first look like ? Specify Y or N Red/inflamed Scurf/Dandruff Scabs/Crusts Hair Loss Other Is your pet itchy? If itchy, the degree of itchiness Does he/she rub or scratch Face Belly Armpits Lick/chew/nibble feet Shake head Bottom Legs Rub/bitedrag the lower back/tail base . Other pls specify Other information Does your pet have any history of ear problems? Yes/No Where does your pet spend most of its time - only indoors, only outdoors, mostly indoors, mostly outdoors, both indoors and outdoors? Where does your pet sleep? Does your pet go for regular walks? Y/N Live near bushland? Y/N Visit Parks Y/N Do you notice the issue worsening when your pet encounters a particular environment? such as grass, freshly mown lawn, other? What do you use for regular flea control, and when was it last applied. Do you bath your pet? If so, what do you use? Did you find it helped, not helped or made no difference? Do you use a conditioner on your pet? If so, what? Please list any previous treatments used for your pet's skin problem, and note whether they helped or did not help. Also note any side effects. Miscellaneous questions What do you feed your pet? Has your pet ever been on a special diet? If so, what was it and did it help? Any history of chronic bowel upsets (diarrhea and or vomiting? Does your pet have any other health problems? Has there been any recent change to..... (answer Y or N) Appetite Y or N Energy Level Y or N Thirst Y or No (if an increased thirst, pls bring in a urine sample if possible) Any other comments? We thank you for taking the time to answer all of these questions. Email or FB messenger photos of your pet's skin. We look forward to helping you and your pet. Don't forget to press the "Submit button" below.
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