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Northwest Eye Careadmin2017-07-06T01:14:30+00:00

Northwest Eye Care

  • Demographic Information

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  • The following demographic questions in regards to race, ethnicity, and preferred language are voluntary.

  • Personal and Family Medical History

    Family History includes your parents, grandparents, siblings, and your children.
  • Including oral contraceptives, aspirin, over-the-counter medications and home remedies.
  • Current Corrective Lenses

  • Social History

    This information is kept strictly confidential.
  • Review of Systems

    Do you currently, or have you ever had, any problems in the following areas:
  • Constituional

  • Integumentary

  • Neurological

  • Eyes

  • Endocrine

  • Ear, Nose, Mouth, Throat

  • Respiratory

  • Vascular/Cardiovascular

  • Gastrointestinal

  • Genitourinary

  • Muscoloskeletal

  • Hematologic/Lymphatic

  • Insurance Information

  • MM slash DD slash YYYY
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