OWNER   ANIMAL
Name   Breed Sex
Tel   Date of birth Weight
File N°   Examined by Date
  START OF SYMPTOMS  
Duration of symptoms
Month Days
Age at start of symptoms
Years Days
Daytime
Nightime
Indifferent
Indoors
Outdoor
Indifferent
Spring
Summer
Autumn
Winter
Indifferent
Observations
  ENVIRONMENT  
Where does the animal sleep?
Material (blanket, cushion, ...)
How long does the animal stay indoors?
Type of floor covering
Furniture covering, Chairs and bedding
Type of Curtains
Indoor plants
Dwelling humid ? Yes No  
 
Presence of other animals ?
Dog(s)
Cat(s)
Bird (s)
Others
Trees outside ? Species
 
Plants, Flowers outside ?Species
 
Grasses, Hay, Cereals outside ? Species
  ALIMENTATION  
Commercial food Cheese Other
Vegetables Bread
Meat Milk
Fish Cod Liver Oil
Eggs Chocolate
  CLINICAL OBSERVATIONS  
Positive reaction to corticoides:
Yes No
Shampoo Used:
Frequency of baths:
by
Ectoparasite:
Endoparasite:
 
  ALLERGIC SYPTOMS  
Rhinitis Conjunctivitis Licking of paws
Sneezing Pruritus Rubbing of head
Diarrhoea Vomiting Asthmatic attacks
Stool Aspect Hyperhydrose
  SKIN CHANGES  
Select a symptom and click on the animal to localise the lesion
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