8650 W. Tropicana Avenue, Ste. B-107, Las Vegas, NV 89147

Reopening Soon!
North Rainbow Veterinary Emergency Hospital
4445 North Rainbow Blvd, Craig & Rainbow, Las Vegas, NV 89108

Phone: 702-871-1152

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Ophthalmology – 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:
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Las Vegas Veterinary Specialty Center | 8650 W. Tropicana Avenue, Ste. B-107 | Las Vegas, NV 89147
Phone: 702-871-1152, Fax: 702-262-7000
Copyright 2015 Las Vegas Veterinary Specialty Center - Las Vegas Veterinarians.

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