Dermatology History Form

Understanding Your Dog's Itchy Skin

Different itching behaviors can indicate different conditions. Please answer a few questions to better understand your dog's skin irritation so we can better help them find a source of comfort.

 

Your Dog's Skin History

Which of the following itchy skin behaviours does your dog experience? *
Does the skin problem happen: *

i.e. anti-itch medications, shampoos, creams, hypoallergenic food, etc.

What was the response to treatment? *
Is your dog currently receiving any parasite control (for fleas/ticks/mites)? *

Your Dog's Itch Score

Please indicate how itchy your dog currently is on the scale below. (0 = no itch; 10 = extremely severe, constant itch) *

Your Dog's Quality of Life

Itchy skin conditions can have a negative impact on your dog's quality of life, as well as your own. This can include an impact on your or their overall comfort or sleeping patterns; your ability to enjoy activities together; or the time and difficulty in administering treatments for your dog's skin.

On the scale below, please indicate how much of an impact your dog's skin condition currently has on your dog. (0 = no impact; 10 = extreme impact) *

Your Quality of Life

On the scale below, please indicate how much of an impact your dog's skin condition currently has on your life, and that of other members of your household. (0 = no impact; 10 = extreme impact) *

Your Dog's Skin Changes

Please tell us where on your dog's body you notice changes in their skin. This may include places where your dog scratches, licks or bites, areas of redness or hair loss; scabs or "pimples" on the skin; or any other skin, ear or feet changes.

Security Question *