Dermatology New Patient Questionnaire Owner's First Name(Required) Owner's Last Name(Required) Pet's Name(Required) Owner 's Email Address(Required) What dermatological problem are you preseting your pet for today?(Required) Your Pet's SymptomsAt what age / date did your pet's symptoms first start? Seasonality - Have you noticed any seasonality to the problem? Worse in Summer Worse in Autumn Worse in Winter Worse in Spring All year round Where does your pet itch? Front feet Back feet Front legs Back legs Face Eyes Left ear Right ear Neck Head Armpits Groin Chest Flanks Stomach Top of tail Anal / Scooting behaviour Shoulder / back Others Please list other areas Does your pet have any of the following gastrointestinal symptoms? Vomiting Gas / flatulence Soft stools Diarrhoea Borborgymus (rumbling or gurgling intestinal sounds) None of the above How many bowel movements does your pet have per day? Less than 2 Greater than 2 Unknown Have you noticed any of the following symptoms? Redness of eyes Runny eyes Runny nose Sneezing Reverse sneezing Coughing None of the above Do you know of any in-contact pets or humans that have the same symptoms as your pet? Yes No Do you know of any related relatives of your pet that have the same symptoms as your pet? Yes No Does your pet have any non-skin/ear related health conditions? Yes No Please list other conditions Your Pet's EnvironmentWhat percentage of time does your pet spend?Indoors?Please enter a number from 0 to 100.Outdoors?What percentage of flooring at home is carpet?Carpet?Please enter a number from 0 to 100.Enter percentage %Hard flooring?Where does your pet sleep? My bed Dog / Cat bed Upholstered furniture Carpet / Rug Outdoor Dog Kennel Others Please list other areas Your Pet's Previous TreatmentsPlease list oral medications (tablets, capsules, liquid) used in the last 12 months.Please list topical medications (shampoos, sprays, creams, lotions, ointments) used in the last 12 months.Please list any ear medications used in the last 12 months.Please list any eye medications used in the last 12 months.Did your pet develop any side effects to any of the medications? If yes, please list below:Your Pet's DietWhat are you currently feeding your pet? Please include all treats / snacks and supplements.Have you tried any special diets for your pet? If yes, please list the diets including the duration of each diet.