Medical History
Please select all medical conditions: |
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Pregnant Or Nursing: |
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Recent Tetanus Shot: |
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Last Visit: |
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Please note any family history conditions: (please select from drop downs below) |
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Illegal Drugs:
Type:
How Long:
STD:
Ocular History:
Eye Meds:
Last Eye Exam:
Doctor:
Glaucoma:
Cataracts:
Macular Degen:
Retinal Detach:
Crossed/Lazy:
Primary Vision Correction:
Back up specs?
Planning to get new glasses?
Other:
Type of CLs worn in
past:
Wear Time:
Cleaner:
Disposal:
Notes:
Race:
Ethnicity:
Preferred Language: