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Please mark Y or N in the first column only if you are currently being treated for Date General ADD/ADHD Anxiety/Depression Asthma/COPD or Emphysema Diabetes High blood pressure/high cholesterol Multiple Sclerosis Rheumatoid arthritis or Ankylosing Spondylitis Sarcoidosis Thyroid abnormalities Do you smoke Do you drink alcohol Are you pregnant/nursing Allergies Cataracts Conjunctivitis pink eye Eyes Corneal Dystrophy Dry Eyes Diabetic Retinopathy Glaucoma Lasik/PRK/RK Macular Degeneration...
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