| Document Date: 2012-02-13 10:24:24
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City Reading / Oakland / / Company REVIEW OF SYSTEMS / / MedicalCondition Glaucoma / Y/N Y/N Y/N Y/N Y/N Y/N RELATION DISEASE/ CONDITION Blindness / __None __Multiple Sclerosis __Osteoarthritis / Double Vision / HIV __Epilepsy __Fibromyalgia __Rheumatoid Arthritis __Cerebral Palsy __Muscular Dystrophy __Lupus __Tumor __Ankylosing Spondylitis __Neurofibromatosis / Non-Insulin Dependent Diabetes __Asthma __High Cholesterol __Insulin Dependent Diabetes __Bronchitis __Stroke / Migraine Headaches / Headaches / Cancer / Disability __Detached Retina __Schizophrenia / Cataracts / DISEASE/ CONDITION Retinal Detachment / __None __Hypertension / Thyroid Disease / Eye Infections / ADHD __Trauma/Large Volume Blood Loss __Macular Degeneration __Depression / eye injury / High Blood Pressure / __Emphysema __Heart Disease __Hormonal Dysfunction __COPD / Macular Degeneration / Leukemia __Colitis __Upper Respiratory Infection / Heart Disease / __Rosacea __Psoriasis Environmental Allergies / Diabetes / __None __Cancer / Anemia __Crohn’s __Hearing Loss / / MedicalTreatment LASIK / eye surgeries / / Position Physician / / Product AND LIST ANY MEDICATION / / ProvinceOrState Alaska / /
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Oakland Vision Oakland Vision Date____/____/______