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Please select if you are a new patient or if your previous visit was longer than 3 years ago.
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Where did you find us?
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Do you use online scheduling?
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Which specialists do you see?
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Want access to online portal?
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Do you have a current optometrist?
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Name of Optometrist
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Who referred you?
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Anything special we need to know
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SSN
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Social History
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Do you smoke?
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Do you drink alcohol?
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Do you do any intravenous drugs?
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What is or was your occupation?
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Who is your Primary Care Doctor?
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Please check if you have or had these symptoms in the past. If yes, fill out the right side:
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General Health Issues
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General Health Issues
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Skin
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Skin
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Head, Eyes, Ears, Nose, and Throat
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Head, Eyes, Ears, Nose, and Throat
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Cardiovascular
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Cardiovascular
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Respiratory
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Respiratory
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Gastrointestinal
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Gastrointestinal
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Urinary
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Urinary
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Musculoskeletal
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Musculoskeletal
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Endocrine
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Endocrine
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Psychological
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Psychological
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Neurological
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Neurological
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Breast
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Breast
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Pregnancy
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Genital (Male Only)
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Genital (Male)
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Genital (Female Only)
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Genital (Female)
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Other
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Past Surgery
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