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Date Format: MM slash DD slash YYYY
What led you to believe your pet is having eye problems?
Pupils have gotten larger
Pupils have gotten smaller
Eye Discharge - watery
Eye Discharge - thick
Eye Discharge - clear
Eye Discharge - white/grey
Eye Discharge - yellow/green
Eye Discharge - rust/brown/black
Change in color or cloudiness of eye(s)
Rubbing eye with a paw or along carpet or furniture
My veterinarian noticed the problem
How long have the symptoms been present?
Did the symptoms start suddenly?
Are the symptoms:
Staying the same
Which eye is affected?
Has the eye problem changed since you first became aware of it?
How has it changed?
Does your pet sleep with eyelids:
Do not konw
Have you treated the eye(s) with any medications?
If yes, please list those medications and how often you are using them
Does your pet exhibit any of these signs associated with vision loss? (check all that apply)
Runs into unfamiliar object - "acts blind when not at home"
Refuses to move - "Lethargic, doesn't want to play, sleeps all day"
Unwilling to jump or climb - "won't jump on the bed anymore"
Refuses to move in darkness - "won't go down the stairs"
Unable to locate moving or stationary object - "won't catch a treat"
Develops aggressive behavior - "now barks at me until he hears my voice"
Seeks security - "stuck to me like glue"
Altered gait - "walks very slowly, very tentative"
Head carried low - "constantly sniffs the ground to navigate"
Is your pet otherwise normal?
Are there other medical problems we need to know about?
If your pet is a cat, is it:
Please list ALL medications your pet currently takes for UNRELATED problems:
Has your pet suffered from any other illnesses?
If yes, what type and when did it occur?
Has your pet had any recent lab work performed?
When was your pet's last dental cleaning?
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