Name First Name Last Name Your pet's name * What symptoms have you noticed in your dog’s ears? (Check all that apply) * Scratching at the ear(s) Head shaking or tilting Ear discharge Redness or swelling in the ear(s) Foul odor coming from the ear(s) Pain or sensitivity when the ear is touched Hair loss around the ear Balance issues Hearing loss Not sure, my groomer told me there's ear infection If you have seen discharge from the ear, what does it look like? Clear Yellow or Brown Black and Waxy Pus-like Blood tinged When did you first notice the ear problem? * Less than 24 hours ago 1-3 days ago 1 week ago More than a week ago How often does your dog show signs of discomfort or ear issues? * Constantly Intermittently throughout the day Only after certain activities (e.g., after swimming) Has your dog been exposed to any of the following recently? Swimming or bathing Outdoor activities in humid or rainy environments Grooming or ear cleaning Allergens (e.g., pollen, dust, etc.) New products such as shampoos or ear cleaners Does your dog have a history of ear infections? * Yes No I don't know, newly adopted Is your dog experiencing any of the following symptoms alongside the ear infection? Vomiting Diarrhea Lethargy Decreased appetite Fever Itching or licking other parts of the body Licking or biting at paws Unsure Does your dog have any known allergies (e.g., food, environmental, medications)? * Yes No Not that I know of If you dog does have allergies, please list them below Is your dog on flea and tick prevention? * Yes No Unsure If yes, what product is used, and when was it last administered? How often do you clean your dog’s ears? * Regularly (weekly/monthly) Occasionally Rarely or never Groomer does it What products do you use to clean your dog’s ears, if any? Is there anything else you would like to mention about your dog’s ear or general health? If your address or phone number has changed, kindly update your new contact details below. Thank you!
