Ophthalmology Information Form

Owner's Name

Pet's Name

Email:

Date of Appointment (M/D/Y)

Is your pet current on all vaccinations? Yes No
Is your pet taking a heartworm preventative medication? Yes No
Has your pet traveled outside of New York? Yes No
If Yes, where and when
Does your pet have any significant medical problem other than the eye(s)?
Are you currently treating your pet with any medications? Yes No
If medications are being given, please list the name(s), amount, and frequencies:
What leads you to believe your pet has an eye problem?
Loss of vision: more in dim light more in bright light?

Eye discharge: watery like pus thick and green

Peculiar color to the eye(s)?Yes No
If Yes, please describe:

Holds eye(s) closed Yes No

Veterinarian noted the problem Yes No

Other:
How long has the problem been present?
Which eye is affected R L Both (check one)
Has the character of the eye problem changed since you first were aware of it? Yes No
If Yes, please describe
How well do you believe your pet sees?
Excellent
Poor on all occasions
Poor especially in: dim light bright light
Poor in regard to: near distant objects
Poor in regard to: moving stationary objects
Do you have other pets? If so, name the type of additional pet (s) and whether or not they have eye problems
Do you know your pet’s dame or sire or littermates? Yes No
If Yes, do any of them have eye problems? Yes No Do Not Know