At What Age Was This Condition First Noticed? ______

General Questions (not all will apply to your pet, tick those you can)

What is the main problem?______

At what age was this condition first noticed? ______.

Has there ever been any previous dermatitis? ______.

Symptoms:

Have any of the following been observed:

____sores ____scabs ____dandruff _____hair loss ____odour ____hives

____heat ____redness ____diarrhoea _____tiredness ____weight loss ____depression

____ear problems _____weight gain ____increased appetite _____increased thirst

Does your pet:

____rub at the face ____lick or chew the paws, which paws______. ______scratch at the sides

____lick the stomach area ____roll on the back ____bite at the tail area ____sneeze

____snort ____wheeze. Other? ______.

Do the symptoms vary?:

If the dermatitis has been present for some time are the symptoms worse:

______Spring ______Summer ______Autumn ______Winter

Are there symptoms present all year round? ______Yes ______No

What (if anything) causes a worsening of symptoms? ______

What helps? ______

Home details:

Do you have any other pets – and if so how many? ____cats ___dogs ___birds ___other

Does any human in the house have skin problems? _____yes ____no

Where does this pet sleep? ______

Have there been any other illnesses? ______

Bathing and fleas:

Does bathing: _____help _____ worsen _____ make no difference

What type of shampoo are you using ______

How often do you prefer to bath your pet? ______weekly ______monthly ______rarely

When was the last time a flea was seen on this pet? ______other pets ______

What is the current flea treatment on this pet? ______

If flea treatment used on other pets? ______

Medication:

If previous medications have been used do you know what they were? ______Yes ______No

What previous medication: ______

If yes: ______shampoos ______rinses _____injections _____tablets _____ointments

Last tablet given (date): ______Last injection given (date): ______

Is your dog on heartworm tablets? ______No ______Yes ______daily _____monthly

Diet:

What do you normally feed your pet: ______cans ____ dry _____meat _____table scraps

If meat - which types? ______

Any other foods? (eg vitamins, toast, biscuits) ______

Have you ever fed a special diet? ______No ______Yes If yes, what ______

What do you think could be the cause of this skin problem? ______