Please list and explain any of the following that you have ever been diagnosed with or treated for: |
Allergies, Asthma, Arthritis, Heart Disease, Cholesterol, Diabetes, |
Kidney Disease, Thyroid Disease, High Blood Pressure, Cancer, Nerves |
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Please list and explain any family history of any of the above: |
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Please list and explain any of the following that you are experiencing or have ever experienced in the past: |
Trouble Seeing at Night, Sunlight Sensitiviy, Floaters/Spots, Double Vision, Crossed Eye, Itchiness, |
Flashes of Light, Blurry Vision, Headaches, Burning, Grittiness, Tearing, Eye Infection, Eye Injury, |
Cataracts, Macular Degeneration, LASIK or RK, Lazy Eye, Retinal Detachment, Iritis/Uveitis, Glaucoma |
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Please list and explain any family history of any of the above: |
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