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Breedlove Eye Center
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2017-07-06T01:14:29+00:00
Breedlove Eye Center
Welcome to Our Office!
Name
*
First
Last
Phone
Email
How did you hear about our office?
Insurance
Internet
Physician
Advertising
Location
Referral
Whom may we thank for referring you?
Do you wear glasses?
Yes
No
How old is your prescription?
Are they polarized?
Yes
No
Do you wear contact lenses?
Yes
No
What brand are they?
What are you interested in?
New Eyewear
Contact Lenses
Learning more about CRT - non-surgical vision correction
What eye surgeries have you had?
Cataract Surgery
Retinal Surgery
Lasik
Other Eye Surgery
Do you currently experience any of the following?
Blurred Vision
Burning
Dryness
Excessive Tearing
Eye Pain/Soreness
Itching
Discharge
Redness
Flashes of Light
Floaters
Sandy Feeling
Glare Sensitivity
Sudden Vision Loss
Double Vision
Vision and Medical History
Please indicate if you or a family member have had history with any of the following conditions.
Cataracts
Patient
Family Member
Diabetes
Patient
Family Member
Macular Degeneration
Patient
Family Member
Eye Injury
Patient
Family Member
Amblyopia/Lazy Eye
Patient
Family Member
Keratoconus
Patient
Family Member
Retinal Detachment
Patient
Family Member
High Blood Pressure
Patient
Family Member
Heart/Carotid
Patient
Family Member
Headache/Migraine
Patient
Family Member
Dry Eye
Patient
Family Member
Arthritis
Patient
Family Member
Neurological/MS
Patient
Family Member
Sinus
Patient
Family Member
Allergy
Patient
Family Member
Hormonal/Thyroid
Patient
Family Member
Please List All Medications:
Please List All Allergies, Including Drug Allergies:
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