Allergic Dermatitis Questionnaire

A survey designed to track the progress of a pet with dermatitis. Please click the NEXT button to start the survey. If you have issues accessing this survey email [email protected] or [email protected]

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

Normal Dog Itching 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.

2-3 days

1 week

2 weeks

4 weeks

6 months

1 year

Has your pet experience any off the following in the past week (Select all that apply or 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)

What diet or dry food do you feed your Pet

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)

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

Flea/ Tick Preventative

Joint Supplements - Glucosamine / Chondroitin etc

Antibiotics

Omega 3 Fatty Acid Supplement (eg Megaderm)

Corticosteroids (Prednisilone / Macrolone)

Non Steroidal pain relief ( Metacam / Carprofen / Gabapentin / Tramadol

Allergy Desensitizing Vaccines

Apoquel

Cytopoint (if given in the last 8 weeks)

Please fill in the comment box below.

Thanks for completing the survey.

Patient Name

Owner Name

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