• 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.
  • SOCIAL HISTORY

  • REVIEW OF SYSTEMS

    Do you currently have any problems in the following areas?
    Please click on the appropriate response

    • EYES
  • EAR, NOSE, MOUTH, THROAT
  • ENDOCRINE
  • NEUROLOGICAL
  • MUSCULOSKELETAL
  • CONSTITUTIONAL SYMPTOMS
  • SKIN
  • CARDIOVASCULAR
  • PSYCHIATRIC
  • GASTROINTESTINAL
  • GENITOURINARY
  • DRUG USE
  • AIDS/HIV POSITIVE
  • RESPIRATORY
  • HEMATOLOGICAL/LYMPHATIC
  • FAMILY HISTORY
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