Skin Allergy Testing Questionnaire – Veterinary Dermatology Center

Once we have your pet’s skin allergy test results, we will need some additional information to ensure we accurately formulate the allergy vaccine injections or sublingual drops (immunotherapy).

Owner Name*
Owner's First Name Owner's Last Name
Pet's Name*
Pet's Name
Date*
Date Format: MM slash DD slash YYYY
Is your pet worse indoors or outdoors? (Check all that apply)*
- Indoors
- Outdoors
Which seasons are worse for your pet? (Check all that apply)*
- Winter
- Spring
- Summer
- Fall
What type of trees do you have in your yard? (Check all that apply)*
- Bayberry
- Red Mulberry
- Box Elder
- Red Cedar
- Bald Cypress
- Live Oak
- White Pine
- Orange Tree
- Pecan
- American Elm
- Black Willow
- Pepper Tree
- Melaleuca
- Queen Palm
- Beefwood/Aust. Pine
- Nettle
- Other
If you have chosen the "Other" field above, please specify below.
What type of grass is in your yard? (Check all that apply)*
- Bahia
- Timothy
- Johnson
- Red Top
- Bermuda
- Perennial Rye
- Other
If you have chosen the "Other" field above, please specify below.
Do you have any history of water damage or mold in your home? If yes, please describe.*
Does your pet have access to a barn or interactions with horses?*
- Yes
- No
Do you have other pet species in the household? If yes, please list them.
Do you have carpeting? If so, approximately how much of your house is carpeted?*
Is the furniture in your house cloth or leather? (Check all that apply)*
- Cloth
- Leather
- Other
If you have chosen the "Other" field above, please specify below.
Do you have drapery or just blinds?*
- Drapery
- Only blinds
- Other
If you have chosen the "Other" field above, please specify below.
Do you prefer injectable (shots) or sublingual (oral) immunotherapy? If you are comfortable giving injections, a technician will teach you how to administer them. Injectable immunotherapy can be converted to sublingual if it is not working for you or your pet.*
- Injectable
- Sublingual