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 (512) 451-0229
In the Capital Plaza Shopping Center in Austin

Our Location

5501B N Interstate 35
Austin, TX 78723-2430

CARING FOR
THE EYES OF TEXAS

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Patient History Form

  • Please print numbers where we may contact you:

  • PATIENT HISTORY

  • Have you been diagnosed with:
  • Glaucoma
  • Cataracts
  • Allergies
  • Migraine or Headaches
  • Lazy Eye
  • Do you experience:
  • Watery or Itchy eyes
  • Dry Eyes
  • Double Vision
  • Floaters or Spots
  • Flashes of Light
  • Have you ever experienced difficulties with any of the following symptoms or disorders?
  • Gastrointestinal
  • Nervous
  • Ears/Nose/Throat
  • Musculoskeletal
  • Cardiovascular
  • Blood/Lymph
  • High Blood Pressure
  • Thyroid
  • Respiratory
  • Skin Disorders
  • Diabetes
  • FAMILY HISTORY

  • Glaucoma
  • Cataracts
  • Macular Degeneration
  • Blindness
  • Diabetes
  • Retinal Detachment
  • Lazy Eye
  • High Blood Pressure
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