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Welcome
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Right Eye Problems
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Left Eye Problems
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How would you describe your issue?
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How bad are your symptoms?
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When did your problems start?
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How did it start?
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What made it worse?
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What made it better?
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Any other problems at the same time?
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When do you have difficulty?
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Medical History
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Overall Eye History
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Past Ocular History - Right Eye
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Past Ocular History Left Eye
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Past Ocular Surgeries Right Eye
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Past Ocular Surgeries Left Eye
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Past Medical History
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Other Medical History
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Past Surgical History
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Other Surgeries?
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Childhood illnesses
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Childhood Immunizations
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Home Sugar Testing?
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Last Sugar Test (Number)
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Hemoglobin A1c?
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Years with Diabetes
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Primary Care Doctor
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Other Primary Care Doctor
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Optometrist
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Other Optometrist
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Ophthalmologist
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Other Ophthalmologist
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Referring Doctor?
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Endocrinologist
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Family History
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Non-contributory?
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Eye Family History
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Family Medical History
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Social History
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Do you smoke?
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Never Smoked?
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Smoking Details
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Do you drink alcohol?
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Do you drink caffeine?
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Marital Status
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Regular Activities/Hobbies
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Living Arrangements
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Review of Systems
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General Problems
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No General Problems
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Skin Problems
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No Skin Problems
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Head/Eye/Ear/Nose/Throat Problems
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No Head/Ear/Nose/Throat problems
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Neck Problems
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No Neck Problems
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Breast Problems
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No Breast Problems
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Heart Problems
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No Heart Problems
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Lung Problems
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No Lung Problems
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Stomach Problems
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No Stomach Problems
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Male Genital Problems
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No Male Genital Problems
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Female Genital Problems
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No Female Genital Problems
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Blood Flow Problems
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No Blood Flow Problems
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Joint/Muscle Problems
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No Joint/Muscle Problems
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Neurologic Problems
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No Neurologic Problems
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Hormonal Problems
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No Hormonal Problems
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Psychiatric Problems
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No Psychiatric Problems
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