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Medical History Questionnaire Name Date DOB Date of last eye exam Place of last eye exam List any medications you currently take prescription and over-the-counter Do you have any allergies to any medications YES NO If yes list the medications List all major illnesses or injuries Arthritis Asthma Atrial Fibrillation Cancer Thyroid disease Diabetes Emphysema Hypertension Heart Attack Kidney Failure/Dialysis Recent Injury/Fall Stroke Other List any surgeries radiation or chemotherapy you have...
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