Health History Questionnaire
( Eye pain ( Eye strain ( Cataracts ( Eye Dryness ( Excessive tearing ( Discharge from eyes ( Poor hearing ( Ringing in ears ( Earaches ( Discharge from ear ( Nose bleeds ( Sinus congestion ( Nasal drainage ( Grinding teeth ( Teeth problems ( Jaw clicks ( Concussions ( Recurrent sore throats ( Hoarseness ( Sores on lips/tongue ................
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