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Initial History Form
Veterinary Eye Specialists
620 Commerce St
Thornwood, NY 10594
(914) 674-4141
Patient's name
*
Your name
*
Today's Date
*
What is your reason for coming in today? Check all that apply.
Note: This refers to the PATIENT's eye, not yours!
Abnormal squinting
Abnormal squinting
A
Right
B
Left
C
Both
Excessive eye (not face) rubbing
Excessive eye (not face) rubbing
A
Right
B
Left
C
Both
Redness
Redness
A
Right
B
Left
C
Both
Discharge
Discharge
A
Right
B
Left
C
Both
Cloudiness
Cloudiness
A
Right
B
Left
C
Both
Other color change
Other color change
A
Right
B
Left
C
Both
Swelling
Swelling
A
Right
B
Left
C
Both
Bulging
Bulging
A
Right
B
Left
C
Both
Large eye
Large eye
A
Right
B
Left
C
Both
Small eye
Small eye
A
Right
B
Left
C
Both
Please describe any additional reasons for the visit below.
Change in or abnormal vision
Eye looks abnormal
Something else
Not sure
Please provide additional relevant details for the eye problem not already described above
When was this first noticed? (if not sure, give an approximation)
*
Has it changed since first noticed?
*
Has it changed since first noticed?
A
Yes
B
No
Have you seen another doctor for this same problem?
*
Have you seen another doctor for this same problem?
A
Yes
B
No
Has your pet had surgery for this problem?
*
Has your pet had surgery for this problem?
A
Yes
B
No
Are you using any medications for this condition now?
*
Are you using any medications for this condition now?
A
Yes
B
No
Does your pet have any other health issues we should know about?
*
(Dogs only) Is your dog on regular heartworm medication?
(Dogs only) Is your dog on regular heartworm medication?
A
Yes
B
No
Is your pet on any other medications, supplements, special foods etc., and if so, what are they, and what are they for?
Is your pet allowed to get treats here in the clinic?
*
Is your pet allowed to get treats here in the clinic?
A
Yes
B
No
How has your pet been feeling lately?
*
How long have you had your pet, and where did you get him/her?
*
Anything else we should know?
(Cats only) Is your cat indoors, outdoors, or both?
(Cats only) Is your cat indoors, outdoors, or both?
A
Indoors
B
Outdoors
C
Both
(Cats only) Is your cat NEGATIVE for FeLV (Feline Leukemia) and FIV (Feline AIDS)?
(Cats only) Is your cat NEGATIVE for FeLV (Feline Leukemia) and FIV (Feline AIDS)?
A
Yes
B
No
C
Not sure
Submit
