EXAM Eye EXAM Eye This form is designed to help our team gather important information about your pet's current status for your upcoming visit to our Fear Free clinic! Your pet's name:* Your name:* Please describe the first time symptoms started*Which eye(s) is affected?* Left eye Right eye Both eyes What colour is the discharge?Is there any redness?* Yes No Is your pet squinting? Yes No Is your pet blinking frequently?* Yes No Is your pet pawing at his/her face?* Yes No Is there any apparent swelling around the eye or other areas of the face?* Yes No Is your pet tilting their head?* Yes No Has there been any trauma, accidents or high-risk activities (such as running through the woods)? Please describe if yes. Have you started your pet on any medications? If so, what medications and what dosage? What kind of food are you feeding your pet? Please upload photos of your pet's food and any treats below: Drop files here or Select files Max. file size: 300 MB. What table scraps/homemade cooking or treats does your pet get?*How long has your pet been on his/her current diet? When was the last time it was changed or he/she was fed something different?*Have you noticed any changes in your pet's personality or behaviours?* yes no Please rate your pet's itchiness score from 1-10, 1 being not itchy at all, 10 being extremely itchy.*12345678910Please rate your pet's stool quality score from 1-5, 1 being profuse diarrhea, 5 being extremely hard.*12345In your opinion, is your pet drinking more frequently?* yes no unsure Has your pet shown any of these signs: coughing, sneezing, itching, diarrhea, vomiting, or lack of appetite?* yes no Any change in grooming or sleeping habits?* yes no unsure In your opinion, is your pet urinating more frequently?* yes no unsure Have there been any recent accidents in the house?* yes no Has your pet's energy levels changed?* more energy less energy no change Does your pet attend grooming/boarding/daycare/dog park facilities?* yes no Does your pet hunt?* yes no Does your pet roam freely outdoors?* yes no Does your pet eat feces/drinks outdoor water from wildlife/other pets/its own?* yes no Was your pet living in or traveling with you to heartworm/tick endemic area in the last 12 months? (States, south west/Northern Ontario)?* yes no Is your pet on heartworm prevention?* yes no Is your pet on flea/tick prevention currently?* yes no Please upload photos of your pet's flea/tick and/or heartworm prevention products below: Drop files here or Select files Max. file size: 300 MB. Do you have any doses left over from last year?* yes no What, if any, medications (over the counter or prescription) does your pet take or have applied routinely?Please submit a picture of any products you are using at homeMax. file size: 300 MB.Have you seen any fleas/ticks on your pet in the last year?* yes no Would you like us to get your pet started on Lyme vaccine?* yes no unsure, I'd like more information How did your pet do after last year's vaccines? Was there any reaction to the vaccines?* yes no Is your pet currently microchipped? Would you in interested in a Tchip for your pet?* My pet is microchipped My pet is not microchipped Yes, please Tchip my pet! Has your pet bitten any person in the last 10 days which broke the skin?* Yes No Please list any questions/problems/concerns for Dr. Jinni that you would like addressed:Does anyone in your household have a peanut allergy?* yes no Δ