Eye Questionnaire Name* Patient Name Last Name Date* 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? Yes No Have you noticed any loss of vision or changes in vision? Yes No Does your pet have trouble seeing at night? Yes No Have you noticed any cloudiness to the eyes? Yes No Is one pupil a different size from the other? Yes No Have you noticed any rubbing at the eyes? Yes No Is one lid droopy? Yes No Which eye?Any sneezing, coughing, trouble breathing? Yes No Explain:Any discharge from the eye(s)? Yes No Please describe:Has your pet ever been tested for glaucoma? Yes No Has your pet ever been tested for dry eyes? Yes No Does your pet have cataract(s)? Yes No Any swelling of the eye(s)? Yes No Explain:Has your pet ever been seen by an Ophthalmology Specialist? Yes No If so, explain:Comments:-
