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19
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1
Name
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First Name
Last Name
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2
What brings you into the office?
*
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Misalignment of the eyes
Double vision
Difficulty seeing
Other
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3
Is there a history of glasses wear in the past
*
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YES
NO
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4
Please specify for how long and how old are current glasses
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5
Any history of patching or prism use?
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YES
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6
Please specify
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7
Any history of eye surgery
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YES
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8
Please specify: date of surgery, type of surgery and which eye
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9
Any other eye problems?
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10
Any medical problems?
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YES
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11
Please specify
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12
Current medications?
*
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YES
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13
Please list prescription and over the counter meds
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14
Any allergies
*
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YES
NO
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15
Please specify
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16
Are there currently any problems in the following areas:
Yes
No
General/ Constitutional
Ear/Nose/Throat
Cardiovascular
Respiratory
Gastrointestinal
Genital/ Kidney/ Bladder
Muscle/ Bones/ Joints
Skin
Neurologic
Psychiatric
Endocrine
Blood/ Lymph
Allergic/ Immunologic
General/ Constitutional
Ear/Nose/Throat
Cardiovascular
Respiratory
Gastrointestinal
Genital/ Kidney/ Bladder
Muscle/ Bones/ Joints
Skin
Neurologic
Psychiatric
Endocrine
Blood/ Lymph
Allergic/ Immunologic
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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17
Tobacco use?
*
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YES
NO
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18
Alcohol use?
*
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YES
NO
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19
Use of drugs or other substances
*
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YES
NO
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