Health and Vision History Form

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Patient Information

Health History

Eyewear Assessment

Contact Lens Assessment

Lifestyle Index

This questionnaire is meant to help you doctor understand what you are experiencing on a regular basis - whether its caused by your eyes, posture, stress, etc. Your responses will help make sure you receive the best care possible.

Review of Health: Are there any health problems or anything for which you being treated that we do not know about?

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