Do you currently have any of the following problems?

Diabetes

High Blood Pressure

Heart Disease

Cancer

Arthritis/Lupus

Sinus

Thyroid Disease

Kidney Disease

Ulcers Digestive

Headaches/Migraine

HIV/AIDS

Fever/Weight Loss

Seasonal Allergies

Cataract

Glaucoma

Detached Retina

Diabetic Retinopathy

Macular Degeneration

Crossed Eye

Amblyopia (lazy eye)

Keratoconus

Eye Infections

Blindness

Do you smoke?

Do you drink alcohol?

Have you ever had any injury or surgery to your eyes?

Do you presently wear glasses?

Do you presently wear contact lenses?

Have you ever worn contact lenses?

Are you planning on getting new glasses today?

Do you have vision care insurance?

Do you have health (medical) insurance?

 

 
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