HomeResourcesFormsOphthalmology – New Patient Questionnaire Ophthalmology – New Patient Questionnaire Thank you for taking the time to completely fill out the following questionnaire. The more we know about your pet, the better we can provide the best medical care.Client Name Pet's Name Date MM slash DD slash YYYY What is your primary concern about your pet today? List any signs/changes that your pet has shown (vision loss, cloudiness, etc.)When did you first notice these problems? Has your pet’s attitude changed? Yes No If yes.......explain Does your pet show any signs of pain? Yes No If yes.......explain Any previous eye problems? Yes No If yes.......explain Is one eye showing more symptoms than the other? Yes No If yes.......explain If there is any vision loss, is it worse in: dark conditions light conditions Did vision loss come on: suddenly gradually Are you aware of any litter mates with possible eye problems? Yes No If yes...explain Did your referring vet start any treatments for the current problem? Yes No If yes...explain Have the symptoms: Worsened Improved Were there any other non-ocular problems that have occurred recently? Yes No If yes...explain Current medications, herbs, vitamins, or supplements your pet is currently receiving at home:Name Strength (mg) # of tab/caplets Frequency given Last Given Refill? Yes No Please click here to add more Add More Name Strength (mg) # of tab/caplets Frequency given Last Given Refill? Yes No Please click here to add more Add More Name Strength (mg) # of tab/caplets Frequency given Last Given Refill? Yes No Has your pet had any reactions to medication? Yes No Yes, Drug Name: Has your pet been treated for any previous medical/surgical problems? Yes No If yes, what and when:Is your pet microchipped? Yes No Has your pet eaten today? Yes No if yes...last meal was at: CAPTCHA
