Patient Name*

Age

Breed

Weight

Owner Name

Phone

Email

Physical Evaluation

Please check any that describe your dog and circle problem areas on the drawing.

Evaluation

Hair loss
Foul odor
Inflammation or redness
Itching and/or scratching
Otitis(ear infection)
Licking and/or chewing
Skin lessons (sores)
Changes in skin (reddish-brown stains, discolorations and/or areas that are thick and leathery)

Other

Does your dog have any chronic gastrointestinal signs such as diarrhea or vomiting?

Yes
No

Has your dog ever had ear problem?

Yes
No

Severity Evaluation

On a scale of 0 to 10 rank the severity of your dog’s symptoms.

Severity of Overall Condition

Please enter a number from 0 to 10.

Severity of Skin Lesions

Please enter a number from 0 to 10.

Severity of Scratching, Licking or Chewing

Please enter a number from 0 to 10.

Onset and Seasonailty Evaluation

Is this first time your dog has experienced these symptoms?

Yes
No

If no, at what age did the symptoms first occur?

<1 year
1-3 years
4-7 years
7+ years

If no, have they occured around the same time of year each time?

Yes
No

How long have the current symptoms been going on?

If no, approximate time of year symptoms occur

Did the itch start gradually and over time become worse?

Yes
No

Did the itch come on suddenly without warning?

Yes
No

Was there a "rash" first or itching first? Or simultaneous?

Rash
Itch
Simultaneous

Parasite Control

Is your dog on a flea or heart worm preventative?

Yes
No

If yes, what products?

What months do you administer the preventative?

When was the last time you administered the parasite control?

Lifestyle Evaluation

Where does your dog environment?

Indoors
Outdoors
Both

If outdoors, please describe environment

Are there other pets in your household?

Yes
No

If yes, do these pets have the same symptoms?

Yes
No

If these pets are cats, do they go outside?

Yes
No

Do you board your dog or take him or her to obedience school, training or groomers?

Yes
No

If yes, when was the last time you took your dog?

Yes
No

If yes, please indicate when and location

Have you recently moved?

Yes
No

Have you been to a new dog park or walking trail?

Yes
No

Have you used any new shampoo or topical skin treatments recently?

Yes
No

Are any humans in your household exhibit signs?

Yes
No

Dietary Evaluation

When pet food are you feeding your dog?

Do you feed the same food all the time or provide a variety?

Always Same
Variety

Have you changed your dog's diet recently?

Yes
No

Do you give your dog packaged treats?

Yes
No

Do you feed your dog "humans" food?

Yes
No

Relationship Evaluation

Indicate if and how your dog’s itching has affected his or her behavior and relationship with you.

Sleeps Through the Night

Always
Usually
Occasionally
Never

Activity Level

Inactive
Much less active
Somewhat less active
No change

Social Behavior

Unsocial
A lot less social
Somewhat less social
No change

Relationships Changes

Fever walks
No longer sleeps in bed or same room
Interact less with family

Prior Treatments

Has your dog treated for itching before?

Yes
No

Indicate previous treatment administered to your dog: (CHECK ALL THAT APPLY)

Steroids
Shampoo
Sprays
Ointments
Antibiotics
Hypoallergenic food
Essential Fatty acids
Antihistamines
Immunotherapy

Other (Please Specify)

Next Steps

Physical Exam:
A Thorough physical evaluation of your dog will help us identify obvious problem and conditions such as parasites.

Laboratory Testing:
Ear Swab- to identify any infections in the ear including yeast and/or bacteria

Skin Scrape/ Hair Pluck- to detect scabies or dermodex mites

Impression Smear/Tape Prep- to detect other parasites and check for presence of yeast and/or bacteria

Itchy Dog Evaluation

Physical Evaluation

Severity Evaluation

Onset and Seasonailty Evaluation

Parasite Control

Lifestyle Evaluation

Dietary Evaluation

Relationship Evaluation

Prior Treatments

Next Steps