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Mango Street Eye Care
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2020-11-06T15:46:30+00:00
Mango Street Eye Care
Name
*
First
Middle
Last
Email
*
Name of Parent or Spouse
*
First
Last
Name of Family Physician
*
First
Last
What Is Your General Health Status?
*
Excellent
Good
Fair
Poor
Name of Last Eye Doctor
*
First
Last
Do You Wear Eyeglasses?
*
Yes
No
Do You Wear Contact Lenses
*
Yes
No
Do You Use Tobacco Products?
*
Current
Previous
Never
Do You Drink Alcohol?
*
Socially
Daily
Never
Patient Eye Health
*
Amblyopia (lazy eye)
Blurred Vision-Far
Blurred Vision-Near
Burning Eyes
Cataracts
Double Vision
Drooping Eyelid
Dry Eyes
Eye Turn
Floaters/Spots
Fluctuating Vision
Foreign Body Sensation
Glaucoma
Glare/Light Sensitivity
Headaches
Itchy Feeling
Infection of Eye/ Lid
Loss of Vision-Central
Loss Of Vision-Side
Mucus/Discharge
Redness
Retinal Detachment
Tearing/Watery Eyes
None of the Above
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