Eye Questionnaire Name* Patient Name Last Name Date* Date Format: MM slash DD slash YYYY Eye QuestionnaireWhen did the eye condition begin?Has this condition been treated before? If so, what medications were used?Have any eye diseases been diagnosed by a Veterinary Doctor before? If so, what was the diagnosis?Which eye is affected? One eye or both?Are the whites of the eyes frequently bloodshot, i.e. red eyes?YesNoHave you noticed any loss of vision or changes in vision?YesNoDoes your pet have trouble seeing at night?YesNoHave you noticed any cloudiness to the eyes?YesNoIs one pupil a different size from the other?YesNoHave you noticed any rubbing at the eyes?YesNoIs one lid droopy?YesNoWhich eye?Any sneezing, coughing, trouble breathing?YesNoExplain:Any discharge from the eye(s)?YesNoPlease describe:Has your pet ever been tested for glaucoma?YesNoHas your pet ever been tested for dry eyes?YesNoDoes your pet have cataract(s)?YesNoAny swelling of the eye(s)?YesNoExplain:Has your pet ever been seen by an Ophthalmology Specialist?YesNoIf so, explain:Comments:-
