Submit PhotoClient Name*Patient Name*Signs of possible canine atopic dermatitis:My dog has been diagnosed with allergies, atopy or atopic dermatitis*YesNoMy dog has hair loss, a rash or skin that is itchy, red, scaly or irritated*YesNoMy dog has experienced ear irritation/infections or skin infections, or recurrent ear problems*YesNoRelationship/Bond:The scratching is disruptive to my dog’s life*YesNoSometimesMy dog can’t seem to get comfortable at night and the scratching keeps my dog (or me) awake*YesNoSometimesThe current treatment for my dog’s skin disease has side e ffects or the treatment schedule is disruptive to our relationship*YesNoSometimesMy dog and I can’t play as much as we used to due to his/her scratching*YesNoSometimesMy dog’s scratching is disruptive to my life*YesNoSometimesImpact of treatment:I have tried the following to relieve my dog’s itch (check all that apply) :* Topicals (shampoo, creams, rinses, etc) Cream Steroids Antihistamines Antibiotics Antifungals Allergy shot OtherTreatments for itch have had the following results (check all that apply) :* Did not control itch well enough Did not control itch long enough Upset stomach from oral meds (vomiting and diarrhea) Increased thirst Increased urination Change in behavior Difficult to maintain OtherThe reality of treatment:My dog does not enjoy taking pills, even in food or treats*YesNoSometimesI cannot apply topical treatments to my dog as frequently as instructed or they are too messy*YesNoN/AGiving medication to my dog on a daily basis is challenging*YesNoSometimesGiving medication on a daily basis is diffi cult to maintain long-term*YesNoThe reality of treatment:My dog is under 12 years of age*YesNoI am interested in a biological treatment that works like my dog’s immune system rather than traditional pharmaceuticals*YesNoMy dog has other conditions or diseases besides itchy skin (check all that apply) :* Diabetes Cushing’s disease Chronic infections Pancreatitis Gastrointestinal issues (eg, ulcers) Cancer Demodex OtherI prefer my dog not to be on steroids*YesNoUnsureI am willing to visit my veterinarian every 4 to 8 weeks for an injection*YesNoSignature*
