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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:
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Name




First




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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
 Book Appointment
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
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