Immunotherapy Questionnaire

Client and Patient Information

Owner Name*

Email Address*

Phone Number*

Patient Name*

Patient Questions

Based on the CAVD ITCH SCALE, what would you rate your pet’s current itch? *

Where on the body does your pet itch? *

How does your pet’s allergies symptoms present? *

Is there anything that you have noticed that makes your pet’s allergies worse or
better? *

Are they on any medications? Including tick/flea prevention. If yes, please provide
details of the product(s) given? How often do you give it? When was it last given? *
YesNo

Details:

Are they on any supplements? If yes, please provide details of the product(s) given?
How often do you give it? When was it last given? *YesNo

Details:

What are you currently feeding? Wet and/or dry? *

Treats? *

What shampoo, mousse, or other topical treatments do you use? If yes, please
provide details of the product(s) used? How often do you use them? When was it last used? *
YesNo

Details:

Do you clean your pet’s ears? If yes, please provide details of the product(s) used?
How often do you clean? When was the last time? *YesNo

Details:

When do you intend to start immunotherapy? *

Any travel outside of Winnipeg since the last exam? *YesNo

Is there a certain time of year that allergies seem to be worse? *

Have you noticed any change in the health or behavior of your pet that coincided
with the development of the skin condition? (e.g. changes in food or water intake, changes in urination or
defecation, changes in activity level). If yes, please provide further details. *
YesNo

Details: