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Ophthalmology History Form

Please submit this form no less than 48 hours before your appointment. Thank You.

Owner's Name Pet's Name

Date of Appointment (M/D/Y)

  1. Is your pet current on all vaccinations? Yes No
  2. Is your pet taking a heartworm preventative medication? Yes No
  3. Has your pet traveled outside of New Jersey? Yes No
    If Yes, where and when
  4. Does your pet have any significant medical problem other than the eye(s)?
  5. Are you currently treating your pet with any medications? Yes No
    If medications are being given, please list the name(s), amount, and frequencies:
  6. 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:
  7. How long has the problem been present?
  8. Which eye is affected R L Both (check one)
  9. Has the character of the eye problem changed since you first were aware of it? Yes No
    If Yes, please describe
  10. 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
  11. Do you have other pets? If so, name the type of additional pet (s) and whether or not they have eye problems
  12. Do you know your pet’s dam or sire or littermates? Yes No
    If Yes, do any of them have eye problems? Yes No Do Not Know

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