Allergy Questionnaire

General History
Your Pet's Name
Your Name
First Last
Your Email Address
Your Phone Number
Secondary Name on Account, if Applicable
First Last
Have you noted a loss in your pet’s weight?
- Yes
- No
Have you noted weight gain in your pet?
- Yes
- No
Have there been any changes in your pet’s activity levels?
- Yes
- No
Have there been any changes in your pet’s energy levels?
- Yes
- No
Have you noticed any changes in your pet’s thirst or urination habits?
- Yes
- No
Has your pet received treatments for intestinal problems/upset in the past?
- Yes
- No
Has your pet had/or currently have any of the following symptoms?
(check all that apply)
- Vomiting
- Gas/Flatulence
- Diarrhea
- Soft Stools
- Bad Breathe
- Inappetance
- Borborygmus (rumbling or gurgling intestinal sounds)
- None
How many bowel movements does your dog have per day?
Have you noticed any of the following symptoms in your pet?
(check all that apply)
- Runny Eyes
- Redness of Eyes
- Runny Nose
- Sneezing
- Coughing
- Snoring
- Reverse Sneezing
- Labored Breathing
- None
Does your pet have any non-dermatology related health conditions or illnesses? If so please provide details:
Dermatologic Symptoms
Approximate date or age of when your pet’s symptoms FIRST started
If problem has been continuous for over a year, did it start off as seasonal?
- Yes
- No
How itchy is your dog currently on a scale of 1 to 10?
Are symptoms getting worse?
- Yes
- No
Is there a time when your pet is more or less itchy?
- Yes
- No
If yes, please provide more details on variations in itch:
Was the “itchiness” the first symptom you noticed?
- Yes
- No
Where does your pet itch?
(select all that apply)
- Face and Muzzle
- Eyes
- Ears
- Neck
- Head
- Front Legs
- Front Paws
- Back Paws
- Armpits
- Groin
- Top of Back
- Chest
- Underbelly
- Anal Area
Environmental Information
How much time does your pet spend indoors?
How much time does your pet spend outdoors?
Type of flooring in your residence
(select all that apply)
- Carpet
- Wood
- Tile
Where does your dog sleep?
(select all that apply)
- Leather furniture
- Upholstered furniture
- Dog Beds
- Outdoor dog house
- Human Beds
- Carpets/rug
- Other
If other, please specify:
Untitled
Name
First Last

Get In Touch

We’d love to hear from you! Use our online form to request an appointment, or give us a call to book over the phone. Contact us any time with questions or concerns.

Address

2755 Fuller Ave.
NE, Grand Rapids, MI 49505

Contact Us

P: (616) 363-3831
@: info@grvetclinic.com

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Hours

Monday: 9:00am-5:00pm
Tuesday: 9:00am-5:00pm
Wednesday: 9:00am-5:00pm
Thursday: 9:00am-5:00pm
Friday: 9:00am-5:00pm
Saturday: Closed
Sunday: Closed

General History

Dermatologic Symptoms

Environmental Information

Get In Touch

Address

Contact Us

Hours