Are you wearing RX glasses?
*
Yes
No
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Since what age have you worn glasses?
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Are you wearing RX contact lenses?
*
Yes
No
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Since what age have you worn contacts?
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Do you have cataract?
*
Yes
No
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Did you have surgery for cataract?
*
Yes
No
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Do you have glaucoma?
*
Yes
No
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Did you have surgery for glaucoma?
*
Yes
No
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Do you have retinal detachment?
*
Yes
No
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Did you have retinal detachment surgery?
*
Yes
No
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Did you have a severe eye injury?
*
Yes
No
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Did you have surgery for this injury?
*
Yes
No
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Did you have a cornea problem or LASIK?
*
Yes
No
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Did you have cornea surgery or LASIK complications?
*
Yes
No
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Do you have any other eye disorder?
*
Yes
No
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What is the other eye disorder?
Did you have surgery for this disorder?
*
Yes
No
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Is your father short-sighted?
*
short-sighted
normal
unknown
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Is your mother short-sighted?
*
short-sighted
normal
unknown
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Thank you for providing this information. We'll reach out to schedule your appointment shortly.
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*
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