Animal Doctor Blue Hills Your Other Family Doctor EYE ISSUES First name * Last name * Preferred contact number. * Patient name * NEW PATIENTS ONLY: How long have you had the patient? NEW PATIENTS ONLY: Where did you get him/her? NEW PATIENTS ONLY: Is the patient microchipped? Yes No Unsure NEW PATIENTS ONLY: Vaccination history (be specific) NEW PATIENTS ONLY: Does the patient have any underlying conditions? Yes No Unsure NEW PATIENTS ONLY: If yes, please explain. How long have you noticed the problem with the eyes? * Which eye is experiencing the problems? * Left Right Both What have you noticed? i.e. redness, blinking, holding the eye shut? * Is there any discharge? If so, what color? * Is your pet (check all that apply): * Coughing Sneezing Pawing at the face Rubbing on carpet None of the above Does your pet have any history of trauma? * Yes No Unsure Have you tried anything at home? Please explain if yes. * Does your pet have any history of allergies? Please explain if yes. * CATS ONLY: How often does your cat go outside? Does he/ she go outside on a leash or on a screened in porch? Is the patient on any medications? Include dosage and frequency. * Are you administering flea/ tick preventative? What type and how often? * Are you administering heartworm preventative? What type and how often? Do we have permission to perform a corneal stain, check intraocular pressure, and/or a tear test? * Yes No Unsure Do you have any additional questions or concerns you would like to address with the Doctor today? * If you are human, leave this field blank. Submit
