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Gastrointestinal Yes/No Nervous Endocrine Ears/Nose/Throat Urinary Blood/Lymph Yes/No Cardiovascular Muscles/Bones Yes/No Allergies Respiratory Skin Headaches High Blood Pressure Yes/No Mental Please explain Diabetes Type Date of Diagnosis Please list medications to which you are allergic Please list current medications Please list any hospitalizations and/or operations Name of family doctor FAMILY HISTORY Yes/No Relation Retinal Detachment Yes/No Relation Glaucoma PERSONAL EYE INFORMATION Do...
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