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Miller and Narahara ODs
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2017-07-06T01:14:30+00:00
Miller & Narahara ODs
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Address Line 2
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Virgin Islands, U.S.
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Åland Islands
Country
Work Phone
Home Phone
Cell Phone
Date of Birth
MM slash DD slash YYYY
Occupation
Employer
Emergency Contact Name
First
Last
Emergency Contact Phone Number
Date of Last Eye Exam
MM slash DD slash YYYY
Dilated?
Yes
No
Referred By
Primary Vision Coverage
Secondary Coverage
Email Address
Medical Information
How is your general health?
Do you take medications for any of these systems? Please check yes or no.
Gastrointestinal
Yes
No
Ears/Nose/Throat
Yes
No
Cardiovascular
Yes
No
Respiratory
Yes
No
High Blood Pressure
Yes
No
Nervous
Yes
No
Urinary
Yes
No
Muscles/Bones
Yes
No
Integumentary (Skin)
Yes
No
Eyes
Yes
No
Endocrine (glands)
Yes
No
Blood/Lymph
Yes
No
Allergic/Immunologic
Yes
No
Headaches
Yes
No
Mental
Yes
No
Please Explain
Diabetes
Yes
No
Which Type?
Allergies to Medication(s)?
Yes
No
What medication(s) are you allergic to? Please also list your reaction(s).
Other Health Problems?
Current Medications?
Have you had any operations?
Yes
No
What kind of operation did you have?
Operation Date?
MM slash DD slash YYYY
Name of family doctor and/or primary care physician
Date of last visit
MM slash DD slash YYYY
Date your blood pressure was last checked
MM slash DD slash YYYY
Family History
High Blood Pressure
Yes
No
Relation?
Diabetes
Yes
No
Relation?
Glaucoma
Yes
No
Relation?
Macular Degeneration
Yes
No
Relation?
Retinal Detachment
Yes
No
Relation?
Cataracts
Yes
No
Relation?
Personal Eye Information
Do you have any eye conditions or problems?
Yes
No
What Kind?
Have you had any eye operations?
Yes
No
Macular Degeneration
Yes
No
Cataracts
Yes
No
Retinal Detachment
Yes
No
Dry Eyes
Yes
No
Blurred Vision
Yes
No
Do you wear glasses?
Yes
No
Contact Lenses?
Yes
No
What type of contact lenses do you wear?
Additional information?
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