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North Park Ophthalmology Patient History Form

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Past Medical History/Review of Systems:
Please check any of the following conditions for which you currently or previously have received treatment:
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Social History:
Do you currently smoke?
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If no, have you in the past?
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Do you drink alcohol?
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If no, have you in the past?
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Family History: Children, parents, or siblings that have had any of the following?
Cataracts
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Diabetes
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Glaucoma
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High blood pressure
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Macular degeneration
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Flu Vaccine
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Pneumonia Vaccine
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Covid-19 Vaccine
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