Medical History Questionnaire

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Eye History

Medical History

Current Medications

Allergies and Medication Intolerances

Social History

Family Medical History

Have any of your blood relatives had or been treated for any of the following conditions? If so, write their relationship to you in the field.

High Blood Pressure

Heart problem

Osteoarthritis

Rheumatoid arthritis

Lung problems

Stroke

Thyroid problems

Diabetes

High cholesterol

Stomach ulcers

Cancer

Dry eyes

Macular degeneration

Glaucoma

Cataracts

Retinal detachment

Keratoconus

Lazy/crossed eye

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