Personal Medical History-Lifestyle 2022

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Please check if any of the following APPLIES to you, and list any medications for each condition that you check.
Cardiovascular:
Endocrine:
Respiratory:
Neurological:
Musculoskeletal:
Immunologic:
Constitutional:
Genitourinary:
Psychiatric:
Hematologic/Lymphatic
Gastrointestinal
Ear/Nose/Throat:
Integumentary:
Allergies (please list)
Alcohol Use:
Tabacco Use (current):
Previous Use?
Have you ever had an eye surgery? (Lasik, cataract surgery, eye injury repair, etc.)

FAMILY HISTORY:

Have you or anyone in your family (Parents, siblings, children, living or deceased) ever been diagnosed with?
Cataracts:
Glaucoma:
Macular Degeneration:
Amblyopia (Lazy eye):
Cancer:
Diabetes:
High Blood Pressure:
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