Allergy Questionnaire – Maybank Mobile Veterinary Services

Please submit the following questionnaire to help us provide the best possible care.

Do you currently have an appointment scheduled?

When is the appointment?

Are you a registered client of Maybank Mobile Veterinary Services?

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Please start by submitting our Request a Booking form. When you have an appointment, you may return to this page and submit the allergy questionnaire.

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 Information

Name *

First

Last

Email *

Name of previous veterinary clinic where we may acquire records:

Pet Information

Species:

Breed:

Sex:

Intact male
Neutered male
Intact female
Spayed female

Age:

General History

At 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.)?

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?

What type of pets are they?

Dog
Cat
Rabbit
Horse/pony
Other

Please explain:

How long have they been present?

Whole life
Many years
More than a year
Less than a year

Dermatologic History

Please 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?

Parasite Control/Prevention

Has 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/Therapeutics

Please 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?

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?

Are you able to give your pet oral tablets/capsules?

Are you able to give your pet oral liquids?

Are you able to apply a spot-on treatment (e.g., flea medications)?

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 Goals

Please briefly describe your hopes, goals, and concerns that you would like to address during your appointment:

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