- PAST HISTORY
Please answer the following questions because problems elsewhere in the body may affect your eyes and vision.
- Do you have a history of any of the following? Please click the appropriate answer.
- If “yes”, please provide information.
REVIEW OF SYSTEMS
Do you currently have any problems in the following areas?
Please click on the appropriate response
- EAR, NOSE, MOUTH, THROAT
- CONSTITUTIONAL SYMPTOMS
- DRUG USE
- AIDS/HIV POSITIVE
- FAMILY HISTORY
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- All information on this form is confidential.
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