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Ophthalmology History




Pet Owner Information


Pet Medical History


1. Is your pet current on all vaccinations? *
2. Is your pet taking heartworm preventative medication? *
3. Has your pet traveled outside of New York? *
5. Are you currently treating your pet with any medications? *
6. Is your pet diabetic? *

Eye Problems


Eye discharge
Peculiar color to the eye(s)?
Holds eye(s) closed
Veterinarian noted the problem
9. How well do you believe your pet sees? *
Poor especially in:
Poor in regard to:
Poor in regard to:
10. Do you have other pets? *
Eye problems
Eye problems
Eye problems
Eye problems

11. Do you know your pet's dam or sire or littermates? *
If yes, do any of them have eye problems?
12. Are you in the medical field? *
If yes, you are a