Please submit the following questionnaire to help us provide the best possible care. Are you a registered client of Maybank Mobile Veterinary Services? Yes No Please start by submitting our New Client Form. When you've registered as a client and have an appointment, you may return to this page and submit the allergy questionnaire.Client InformationName(Required) First Last Email(Required) Name of previous veterinary clinic where we may acquire records:Pet InformationSpecies: Dog Cat Breed:Sex: Intact male Neutered male Intact female Spayed female Age:General HistoryAt what age was your pet acquired?How was your pet acquired (breeder, shelter, etc.)?Any current diagnosed medical conditions?Does your pet have any coughing, sneezing, vomiting, or diarrhea? If so, for how long?Has your pet ever been aggressive to humans or other animals at home or at the vet? If so, please explain.When was your pet last vaccinated and against what (Rabies, Distemper, Leptospirosis)?Describe your pet’s lifestyle/use (hunting, agility, etc), and what % of time indoor/outdoor?Describe outdoor environment: wood/trees, lawn, fields, etc?Describe your indoor environment: carpet, wood, tile, basement?Any recent changes in your home environment (new home, new family member, work being done on house, etc.)? Yes No Please explain:Does your pet swim? If so, where (pond, lake, pool, river)?Is your pet exposed to wildlife (deer, rabbit, squirrel, fox, etc.) in their yard? If so, what?Travel history outside of British Columbia?Are there any other pets in the house? Yes No What type of pets are they? Dog Cat Rabbit Horse/pony Other How long have they been present? Whole life Many years More than a year Less than a year Please explain:Dermatologic HistoryPlease describe your pet’s main dermatologic problems (skin, ears, paws, itching, hair loss, etc.):What is your main concern for the appointment?When did the problem start?How old was your pet when the problem first started? 5+ years 3-4 years 1-2 years 7-12 months 0-6 months Unknown Compared to when it first started, is the problem: Better Worse Much the same What were the first signs of the problem that you noticed? Hair loss Flaky skin Rash Scabs Scratching normal skin Scratching abnormal skin Pimples Sores Redness Dark skin Blackheads/comadones Masses Other Please describe:Did they occur suddenly or gradually? Suddenly Gradually Where on the body did the problem(s) begin? Nose Ears Eyes Chest Rump Sides Abdomen Neck Back Groin Claws Front legs Front paws Pads Tail Back legs Back paws If your pet is itchy, please try to enumerate the severity in the following 0-10 scale: 9-10: Extremely severe, almost continuous, itching doesn't stop whatever is happening (needs to be physically restrained from itching), wakes up itching during the night. 7-8: Severe itching, prolonged episodes, itching might occur at night (if observed), and also when eating / playing / exercising, unable to distract from itching. 5-6: Moderate itching, regular episodes, itching might occur at night (if observed), but not when eating / playing / exercising, difficulty to distract from itching. 3-4: Mild itching, periodic episodes, won't itch while sleeping / eating / playing / exercising, easily distracted from itching. 1-2: Very mild itching, only occasional episodes, pet is slightly itcher than what is considered acceptable. 0: I don't think itching is a problem. What time of year are symptoms at their worst (please check all that apply)? Spring Summer Fall Winter All year Varies but no pattern Has the problem/dermatitis spread? If so please describe.Are there any changes in your pet's thirst? Drinks more Drinks less No change Are there any changes in how often your pet urinates? More Less No change Are there any changes in your pet's appetite? Hungrier Less hungry No change Are there any changes in your pet's weight? Gained weight Lost weight No change Does your pet ever have any of the following hay-fever type symptoms? Runny/itchy eyes Sneezing/wheezing No, my pet doesn't exhibit these symptoms. Do you have any dermatologic history about your pet's parents or littermates?Do any other pets or people in the household have skin/breathing problems? Yes No Parasite Control/PreventionHas your pet ever had fleas or ticks? If so, when was the last time they were seen?What flea/tick preventatives do you use? How often? Year-round?Are all other pets (cats and dogs) on flea prevention as well? If so, please elaborate.What internal parasite prevention is your pet taking? How often? Year-round?Has your pet ever been diagnosed with a tick-borne disease? If so, please describe.For cats, has your cat been FeLV/FIV tested? What were the results? Please write N/A if your pet is not a cat.Diet/Medication/TherapeuticsPlease list everything that your pet eats/drinks below, and please specify wet/dry/pouches/raw, etc.Main food:Treats:Supplements:Drinks (water/milk - please list all):Other:Have you ever fed a strict prescription diet or fed a home-cooked diet with a novel protein guided by your vet to rule out a food allergy? If so, explain.Are you able to bathe and shampoo your pet? Yes No How often does your pet get bathed/groomed?What products are used when your pet is bathed/groomed?Does bathing/grooming help, make worse, or no change?Are you able to apply lotions, creams, or sprays to your pet's skin? Yes No Are you able to give your pet oral tablets/capsules? Yes No Are you able to give your pet oral liquids? Yes No Are you able to apply a spot-on treatment (e.g., flea medications)? Yes No Have you tried any of the following? Antihistamines (Benadryl, chlorpheniramine, Zyrtec, etc.) Antibiotics (Clavamox, cephalexin, Baytril, etc.) Steroids (prednisone, dexamethasone, etc.) Nonsteroidal anti-inflammatories (Rimadyl, Metacam, Deramaxx, etc.) Antiyeast meds (ketaconazole, fluconazole, terbinafine, etc.) Allergy shots Cytopoint injection Atopica (cyclosporine) Apoquel Topical ointments/sprays/wipes Ear cleaners or medicated ear ointments/drops Medicated shampoos or conditioners Omega fatty acids or other supplements/vitamins My pet has not tried any of these types of medications/products. If you have tried any of the above medications/products, please list NAME, DOSE, INTERVAL, and please specify if they were helpful. If your pet has not tried any of the above, please write N/A.Please list all current medication and exact dose/frequency:Does your pet have any known allergies to medications? Yes No Maybe Please explain:Overall GoalsPlease briefly describe your hopes, goals, and concerns that you would like to address during your appointment:Please note: We typically reply to all communications within 24 hours during the week. If you haven't heard from us within that time, please check your junk mail folder.
