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Precision Eyecare
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2017-07-06T01:14:28+00:00
Precision Eyecare
Name
*
First
Middle Initial
Last
Nickname/Preferred Name
Parent/Guardian Name
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
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Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
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Heard and McDonald Islands
Holy See
Honduras
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
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Jordan
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Kenya
Kiribati
Kuwait
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Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
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Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
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Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Cell Phone
Date of Birth
Month
Day
Year
SSN
Email
Occupation
Employer
Work Phone
Emergency Contact Name
Emergency Contact Phone
Name of Family Doctor
Date of Last Visit
MM slash DD slash YYYY
Date of Last Eye Exam
MM slash DD slash YYYY
Preferred Language
English
Spanish
Ethnicity
Hispanic/Latino
NOT Hispanic/Latino
Race
White
American Indian
Asian
African American
Pacific Islander
Native Alaskan
Medical Information
Do you have problems with any of the below systems? Check any that apply.
Gastrointestinal
Ear/Nose/Throat
Cardiovascular
Respiratory
High Blood Pressure
Neurological
Urinary
Muscles/Bones
Integumentary (Skin)
Eyes
Endocrine (Diabetes)
Blood/Lymph
Allergic immunologic
Headaches/Migraines
Psychiatric
Please explain any of the above selected:
Height
Weight
Allergies to Medications?
Yes
No
Which medications?
Medications currently taken
Are you currently pregnant or breast feeding?
Yes
No
Do you currently or have you ever smoked?
Yes
No
Drink alcohol?
Yes
No
Have a history of STD?
Yes
No
List any operations you have had:
Family History
Do you have family history of the following? If yes, please check and indicate relation below.
High Blood Pressure
Diabetes
Glaucoma
Macular Degeneration
Cataracts
Retinal Detachment
Relation?
Personal Eye Information
Do you have any eye conditions or problems?
Yes
No
What kind?
Have you had any eye operations?
Yes
No
Type of operation and date of procedure?
Have you had an eye injury?
Yes
No
Kind of injury and date?
Do you have glaucoma?
Yes
No
Do you have Macular degeneration?
Yes
No
Do you have cataracts?
Yes
No
Do you have retinal detachment?
Yes
No
Do you have dry eyes?
Yes
No
Do you wear glasses?
Yes
No
Do you wear contact lenses?
Yes
No
Additional Information:
Signature
Date
MM slash DD slash YYYY
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