Skin Rashes & Itchiness Fill out this questionnaire before your medical problem visit to help us be as thorough as possible during your appointment.Your Pet's Name* Your Name* First Last Preferred Email Address* Preferred Phone Number*Is this number a cell phone?* Yes No Which method(s) of communication do you prefer?* Text Messaging Phone Call E-mail Please list all medications and supplements your pet receives. Please include when the last dose was given. Please list the current dose and frequency given.*Please describe your pet's diet, including treats. Please describe the amount, frequency, and brand/type.*Are there any changes or differences in environment / housemates / schedule at home? If so, please explain below.*What flea prevention is your pet on and when was their last dose?*Does your pet seem itchy?* Yes No Is your pet shaking his or her head?* Yes No When was the problem first noted?* Where on the body was the problem first noted?* Are any other pets at home experiencing similar problems?* Yes No Have you been treating with anything at home, including shampoos, ointments, or oral medications?*Any there any other concerns you are seeing at home?*
