Opt Medical History Patient Details

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Opt Medical History Contact Information

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Opt Medical History Medical History

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Do you currently have any problems in the following areas, please check the box and provide information.

  •  Diabetes (Type 1)
  •  Diabetes (Type 2)
  •  High Blood Pressure
  •  Cancer
  •  Ears/Eyes/Nose Throat (Stuffy nose, ear ache, etc)
  •  Fever
  •  Weight loss
  •  Respiratory (congestion, wheezing. etc.)
  •  Gastrointestinal (stomach upset ,diarrhea, constipation, etc.)
  •  Genital, Kidney, Bladder (painful urination, frequent urination, impotence, etc.)
  •  Muscles, Bones, Joints (Joint pain, stiffness, swelling, cramps, etc.)
  •  Skin(pimples, warts, growths, rash, etc.)
  •  Neurological (numbness, headache, etc.)
  •  Psychiatric (anxiety, depression, insomania)
  •  Endocrine (diabetes, hypothyroid, etc.)
  •  Blood/Lymph (cholesterolemia, anemia, etc.)
  •  Allergic/Immunologic (sneezing, swelling, redness, itching, hives, etc.)
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

Opt Medical History EYE History

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  •  Loss of Vision
  •  Blurred Vision
  •  Fluctuating Vision
  •  Distorted Vision (halos)
  •  Glare or light sensitivity
  •  Loss of side Vision
  •  Double vision
  •  Dryness
  •  Mucous discharge
  •  Redness
  •  Sandy or gritty feeling
  •  Itching
  •  Burning
  •  Foreign body sensation
  •  Excess tearing or watering
  •  Eye pain or soreness
  •  Infection of eye or lid
  •  Tired eyes
  •  Crossed eyes, lazy eye
  •  Drooping eyelid
  •  Yes
  •  No
  •  new glasses
  •  contact lenses
  •  Vision correction surgery
  •  Yes
  •  No
  •  Yes
  •  No
  •  Soft
  •  Rigid
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Opt Medical History Family History

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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

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