Allergic Dermatitis Questionnaire – Kalinga Park Veterinary Surgery

Name(Required)

First Last

Email(Required)

Select One of the following Categories based on how you feel your dog is today?(Required)

Normal Dog Itching is not really a problem todayhing is not really a problem today

Very mild itching occasional episodes of itching. The dog is slightly more itchy than before the problem began

Mild itching. More frequent episodes of itching. May notice occasional episodes of itching at night. No itching when sleeping, eating, playing, exercising or when being distracted.

Moderate itching. Regular episodes of itching when the dog is awake. Itching might occur at night and wake the dog. No itching when eating, playing, exercising or when being distracted

Severe itching. Prolonged episodes of itching when the dog is awake. Itching occurs at night and also when eating, playing, exercising, or when otherwise distracted.

Extremely severe itching. Dog is scratching, chewing, licking almost continuously. Itching practically never stops, regardless of what else is happening around the dog.

How long has it been since your dog was given anti allergy medication (just select the closet answer) This only refers to medication that was given specifically to stop or treat your dogs itching.(Required)

Has your pet experienced any of the following in the past week (Select all that apply or None)(Required)

None

Diarrhoea

Vomiting ( frequency and time frame in the comment field)

Lethargy

Anorexia - this means they are not eating

Polydipsia - Increased water consumption (please estimate in the comment field)

Comments

Please elaborate on the problems you have seen

What diet or dry food do you feed your Pet(Required)

Royal Canin Anallergenic

Royal Canin Hypoallergenic

Royal Canin Sensitivity Control

Hills Prescripton Z/D

Hills Prescription D/D

Hills Canine Sensitive Stomach

Ivory Coat - Grain Free Adult Food (multiple types)

Other(Enter details in the comment field)

Describe your pets food

Please include brands if appropriate

Please select all other medications or supplements you are also using currently.

Other Medications

Please include brands if appropriate