Name *

Email *

Pet's Name *

Pet's Breed

Pet's Age / DOB (if known)

Pet's Sex

Spayed / Neutered?

How long have you owned this pet?

What are your goals in seeing an ophthalmologist today?

At what age did your pet's eye problem FIRST start? Please include the earliest time that you noticed any issues, even if it was during a prior year.

Did this particular eye problem progress gradually or have a sudden onset?

Is/was the problem originally worse during any time of the year? If yes, what months or seasons?

Please rate your pet’s current level of eye discomfort on a scale of 1-10 (10 being the most severe).

The term “eye discomfort” includes redness, discharge, squinting, rubbing eyes, etc.

If your pet’s eye problem varies throughout the year, please give a score at the various times.

If your pet is experiencing eye discomfort, are there times of the day when it is worse? Does the discomfort occur indoors, outdoors, or both?

Are any animals or people that are in contact with your pet experiencing any eye issues since your pet’s problems started?

Are there any other pets at home or to which your pet is exposed? (for example, does your pet spend time at dog parks, day care, with visitors, or elsewhere?)

Does your pet stay at any different houses- if yes, does the eye problem worsen/ improve/ or remain the same?

Check all areas where your pet shows signs of discomfort or irritation:

Eyes
Eyelids
Face
Head
Nose

Food

What kind of food does your pet eat (dry vs. canned, brand if known)?

Has your pet’s diet ever been changed to another diet to see if it would improve the current eye condition?

If yes to the above, which other foods were tried and how long did your pet eat each one?

What kind of treats, “table food” or bones do you give your pet?

Does your pet receive any vitamins or dietary supplements? If so, list.

Medication

Are you currently using any flea preventative for your pet? If yes, what kind and how often do you administer?

Are you currently administering heartworm preventative? If yes, what kind and do you give it year-round or seasonally?

Please list current medications, eye drops, or other treatments (for eyes) and supplements that you are using. Include strength (if applicable) & how often it is given/used along with your pet’s response to these treatments and any side effects.

Please list previous medications, eye drops, or other treatments given/applied for your pet’s current problem – make sure to note your pet’s response and any side effects.

General Health Assessment

Besides eye problems, is your pet experiencing any vomiting, diarrhea, coughing, or discharge from the nose or eyes? If yes, please note how often and from which nose or eye (if applicable).

How many bowel movements does your pet have on an average day?

Has your pet’s water drinking or number of urinations per day or amount of urination changed recently? If yes, in what way?

Has your pet’s energy level decreased?

Has your pet experienced any unexpected weight loss or weight gain?

Environmental History

What state(s) has your pet spent time in?

Recent Travel? Where?

Describe where you live (suburbs, rural, city)

% of time pet is indoors?

Please enter a number from 0 to 100.

% of time pet is outdoors?

Where does your pet sleep? (Include type of bedding if applicable)

What types of plants and grasses are in your house and yard?

What types of trees are in your neighborhood?

Is this pet around other animals? If so, what species/breeds?

Is the pet exposed to cigarette smoke?

What type of flooring is present in your house?

Behavior History

We want to make sure your pet’s experience at the ophthalmology center is as enjoyable and stress-free as possible. Please answer the following questions to the best of your ability so we can adjust our care to better serve and comfort your pet.

During travel to the veterinary hospital, does your pet show any of the following behaviors?

Eager and excited
Bark/Meow
Whine
Pant
Reluctant
Hide
Urinate/BM
Subdued
Drool
Vomit
Tremble
Pace
Other

How would you describe your pet around other animals and people?

Does your pet have any sensitive areas that he/she does not like to have touched by you or others?

Please note if you have any difficulty:

Bathing your pet
Applying medications
Giving medications by mouth
Other

Has your pet ever been prescribed any supplements or medications to help with a visit to a veterinary hospital? If so, what was it and what kind of results did you experience?

Thank you for taking the time to complete our questionnaire. Please add any other information that you feel may be helpful to us in treating your pet along with additional questions or concerns you want to have addressed at your pet’s appointment:

St. Louis Veterinary Ophthalmologists

History Form

History Form

Food

Medication

General Health Assessment

Environmental History

Behavior History

Need to schedule another appointment?

Our Offices

Contact Information

Hours

Kirkwood

Ellisville

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