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Patient History Form

  • SurgeryDate 
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  • YesNo
    Flashing Lights
    Floating Spots
    Glare/Halos
    Sensitivity to Light
    Loss of Peripheral Vision (side vision)
    Loss of Vision (Sudden Blindness)
    Double/Blurry vision
    Itchiness
    Burning/Red/Dry/Teary
    Pain
    Gritty Feeling Eyes
    Discharge
  • Please specify type of cancer and whether past, present or in remission.
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