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Jerry Jacobs, OD
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2017-07-06T01:14:26+00:00
Jerry Jacobs, OD
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Are you interested in new glasses?
Yes
Possible, if needed or changed
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Contact Lenses
If not wearing contact lenses, are you interested in being fitted?
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Do you see well with your current contact lenses?
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High Blood Pressure
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HIV +
Have you been diagnosed with Diabetes?
If yes, how long ago?
Headaches
If yes, how often and what part of the head?
Are they dull, sharp, severe, migraine? When do they occur?
Family Medical History
Glaucoma
Diabetes
Macular Degeneration
Crossed eyes
Are you interested in a refractive surgery procedure? (Lasik, PRK, etc.)
Yes
No
Possibly later
Other conditions which may be significant?
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