Itching Questionnaire

  • Date Format: MM slash DD slash YYYY

  • PHYSICAL EVALUATION

  • SEVERITY EVALUATION

  • On a scale of 1-10 (0 being no symptoms, 10 being severe), rank the severity of your dog's symptoms:
  • On a scale of 1-10 (0 being no symptoms, 10 being severe), rank the severity of your dog's symptoms:
  • On a scale of 1-10 (0 being no symptoms, 10 being severe), rank the severity of your dog's symptoms:

  • ONSET AND SEASONALITY EVALUATION

  • PARASITE CONTROL

  • If so, what product?

  • LIFESTYLE EVALUATION

  • If outdoors, please describe the environment.
  • If yes. do these pets have the same symptoms? If these pets are cats, do they go outside?
  • If yes, when was the last time you took your dog?
  • If yes, please indicate when and location

  • DIETARY EVALUATION

  • RELATIONSHIP/BEHAVIOURAL EVALUATION

  • PRIOR TREATMENTS

  • Check all that apply