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Patient Form

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  • Feet
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Primary Care Physician
Medication Allergies
Current Medications
Medical History
Do you currently have any of the following problems?
Have you ever been treated for any of the following?
Do you have any of the issues with your eyes?
Have you ever been treated for or diagnosed with the following conditions?
Please note any family with the following conditions
(F = Father, M = Mother, S = Sibling, GP = Grandparent)
Social History: Check which substances you use and the consumption