Demographics
Pregnant Or Nursing |
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Relationship |
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Review of Systems: Please indicate if you have problems
with any of the following: |
GENERAL: Fever, Weight loss, Weight gain, Fatigue |
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INTEGUMENTARY: Growths, Rashes, Acne |
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NEUROLOGICAL: Headaches, Migraines, Seizures |
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ENDOCRINE: Thyroid, Diabetes |
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EAR, NOSE, MOUTH, THROAT: Allergies, Sinus, Cough, Dry
Mouth/Throat |
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RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD |
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CARDIOVASCULAR: Hypertension, Heart Surgery, Vascular
Disease, High Cholesterol |
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GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux |
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GENITOURINARY: Kidney Stones, Frequent Urination,
Impotence, BPH |
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MUSCULOSKELETAL: Athritis, Joint Pain, Head or Neck Injury |
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HEMATOLOGIC/LYMPHATIC: Anemia, Bleeding problems |
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ALLERGIC/IMMUNOLOGIC: Seasonal Allergies, Allergy Shots |
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PSYCHIATRIC: Depression, Anxiety, Insomnia |
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Year of last full exam |
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Age of glasses (year) |
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How do you wear your glasses? |
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Please scroll to the top of the page and fill out insurance information
(our office can accept most major medical insurance and vision
insurance plans), and then select the SUBMIT DATA tab. You will then be
done with the registration!