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E-Mail Address :
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Pet's Name (required)
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Breed (required)
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Color (required)
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Birthdate or age (required)
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Regular veterinarian/clinic (required)
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What led you to believe your pet had an eye problem? |
Eye discharge
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Change in eye color
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Rubbing
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Eye held closed
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Loss of vision
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Eyelid swelling
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Veterinarian noted problem
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Decreased vision for near objects
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Decreased vision for far objects
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Decreased vision for moving objects
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Decreased vision in dim or dark light
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Decreased vision in bright light
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Other
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How long as the problem been present? (required)
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Which eye is affected? (required) :
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Current medications used to treat the eye condition
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Previous medications
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Response to treatment :
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Has your pet had any previous eye problems? (required) :
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If yes, what type?
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Has your pet had any other health problems? |
heart/lungs/high blood pressure
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brain/spinal cord
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kidney/urinary tract
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immune system/blood
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teeth/stomach/intestines
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skin
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joints/bone/muscle
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endocrine (thyroid, diabetes, Cushing's, Addison's)
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cancer
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Describe health problems indicated
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Please list any current systemic medications, heartworm medication, or food supplements
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Have you noticed any of the following symptoms in recent months? |
excessive thirst
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increased urination/accidents in the house
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loss of appetite
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increased appetite/weight gain
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vomiting
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diarrhea
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coughing
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problems with hearing
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abnormal mentation or behavior
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abnormal gait
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Does your pet have a history of allergies? (required) :
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If yes, describe
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Has your pet ever had an autoimmune disease? (required) :
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If yes, describe
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Has your pet had anesthesia in the past 12 months? (required) :
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What are you currently feeding your pet?
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Do you know your pet's dam or sire (parents)? (required) :
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Do you have other pets? (required) :
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If yes, do they have any eye problems? :
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If yes, describe
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