Language
English (US)
Spanish (Latin America)
Ophthalmology Initial Visit Questionnaire
Please complete prior to your appointment
Your pets name
*
Your name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of appointment:
*
How long have you had your pet?
*
Has your pet traveled outside the Bay Area in the past 12 months?
*
Yes
No
If so, where?
Does your pet usually need a muzzle or special precautions for exams?
*
Yes
No
Unsure
Please list any medical conditions your pet has:
Does your pet have allergies to environment, food or medications?
*
Yes
No
Unsure
If yes, list here:
In the past month, has your pet shown any signs of disease of the body (not of the eye)? Please check all that apply
*
Increased drinking
Increased urination
Coughing
Sneezing
Nasal discharge
Vomiting
Diarrhea
Lack of energy
Lack of appetite
Ear problems
Dental Problems
None of the above
Does your pet have any skin problems? Check all that apply:
*
Itching/Scratching
Fleas
Ticks
Hair loss
Paw licking
Skin redness
Pustules
None of the above
What brings you in today?
*
Which eye(s) are affected?
*
Right
Left
Both
Please check any ongoing eye related symptoms (check all that apply):
*
Redness
Squinting
Loss of vision
Corneal opacity / cloudiness
Ocular discharge
Rubbing eye(s)
NONE of these
Other
Is your pet currently receiving any medications BY MOUTH?
*
Yes
No
List all ORAL medications that your pet currently receives. Please fill out as much as possible.
Is your pet on any eye medications currently?
*
Yes
No
List all EYE medications that your pet currently receives. Please fill out as much as possible. This helps us ensure our previous instructions were comprehensible
Please list any questions or concerns you would like to address with the ophthalmologist:
Optional - Submit photo(s) or video related to any questions or concerns
Browse Files
Cancel
of
The ophthalmologist will always discuss the most common and/or serious side effects of any medication prescribed. In addition, we are legally obligated to offer you additional drug counseling, including an additional conversation and drug insert. Please sign here that you understand that at the end of the appointment you are entitled to request additional information about any new medication prescribed.
*
Client or Agent
Submission Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: