Glaucoma - Jones Vision Polaris
Last Dental Treatment _____ Procedure _____ Referred By _____ ... - glaucoma NO YES - hives or skin rash NO YES - thyroid trouble NO YES - fainting spells or seizures (epilepsy) NO YES - porphyria NO YES - illness that lasted more than one week NO YES - Diabetes NO YES - Other NO YES - allergy NO YES Please list any allergies, including allergies to medications: 13. Are you . presently taking ... ................
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