We appreciate you choosing us for your professional eye care.
LIFESTYLE QUESTIONNAIREThis will allow us to make recommendations for your specific eye care needs!
Please check the box if you prefer to discuss the following information with the doctor only.
Do you use tobacco products?
Do you drink alcohol?
If yes, type / amount / how long:
Do you use illegal drugs?
Do you have any eye problems?
Review of Systems - Please check all that apply or fill in the blank for those not listed.
Family History List the family member(s) that has/had the following: (Ex. Mother, Grandparent, etc)
All EyeCare Services
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One fine body…