Billing Information
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Primary Medical
Not Primary on Account:
Vision Plan
Not Primary on Account:
Rtn Vision w/Medical
Not Primary on Account:
Rtn Vision w/Medical
Not Primary on Account:
Medical History
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What is the reason for your visit today?: |
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Ocular History: |
Have you been diagnosed with any of the following eye conditions? |
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Medical History: |
Do you have or have you had any of the following? |
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Allergies: |
Are you allergic to any of the following? |
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Family Ocular and medical history: |
Has anyone in your family had any of the following? |
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History of Present Illness: |
Are you currently experiencing any of the following? |
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Do you have any history of eye surgery?: |
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Medications: |
Are you currently taking any medications, vitamins or supplements? Please list here |
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Pregnant or trying to get pregnant?: |
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Nursing?: |
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Review of Systems:
General: |
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Ear/Nose/Throat: |
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Cardiovascular: |
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Respiratory: |
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Genitourinary: |
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Gastrointestinal: |
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Endocrine: |
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Musculoskeletal: |
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Skin |
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Neuro |
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Psych |
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Blood/Lymph: |
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Immune |
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Social History:
Do you ever smoke or use tobacco products? |
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Do you drink alcohol? |
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