Family History Template - Blindness/low Vision Page 2

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Mother
Father
Sibling
Child
 Brain Cancer
 Eye Cancer
 Migraine
 Multiple Sclerosis
 Neurological Disorder
 Prostate Cancer
 Seizures
 Sickle Cell anemia
 Sickle Cell Trait
 Thyroid Disease
 Visual Disturbance
Medication name-please also
Milligrams
Number of
Times you
specify if it is a tablet, capsule or
capsules/
take per
injection
tablets
day
Are you interested in LASIK?
YES
NO
MAYBE

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