Companion Animal Eye Center, Ltd.

4708 Olson Memorial Hwy
Golden Valley, MN 55422

(763)529-7591

www.companionanimaleyecenter.com

New Pet History

Name (required)
First Name (required)
Last Name (required)
Address (required)
Street Address (required)
City (required)
,
State / Province (required)
Zip / Postal Code (required)
Phone (required)
Phone TypePhone Number (required)
Phone
Phone TypePhone Number
E-Mail Address :
Pet's Name (required)

Breed (required)

Color (required)

Birthdate or age (required)

Regular veterinarian/clinic (required)

What led you to believe your pet had an eye problem?
Eye discharge
Change in eye color
Rubbing
Eye held closed
Loss of vision
Eyelid swelling
Veterinarian noted problem
Decreased vision for near objects
Decreased vision for far objects
Decreased vision for moving objects
Decreased vision in dim or dark light
Decreased vision in bright light
Other
How long as the problem been present? (required)

Which eye is affected? (required) :
Current medications used to treat the eye condition

Previous medications

Response to treatment :
Has your pet had any previous eye problems? (required) :
If yes, what type?

Has your pet had any other health problems?
heart/lungs/high blood pressure
brain/spinal cord
kidney/urinary tract
immune system/blood
teeth/stomach/intestines
skin
joints/bone/muscle
endocrine (thyroid, diabetes, Cushing's, Addison's)
cancer
Describe health problems indicated

Please list any current systemic medications, heartworm medication, or food supplements

Have you noticed any of the following symptoms in recent months?
excessive thirst
increased urination/accidents in the house
loss of appetite
increased appetite/weight gain
vomiting
diarrhea
coughing
problems with hearing
abnormal mentation or behavior
abnormal gait
Does your pet have a history of allergies? (required) :
If yes, describe

Has your pet ever had an autoimmune disease? (required) :
If yes, describe

Has your pet had anesthesia in the past 12 months? (required) :
What are you currently feeding your pet?

Do you know your pet's dam or sire (parents)? (required) :
Do you have other pets? (required) :
If yes, do they have any eye problems? :
If yes, describe


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