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Systematic Health

Please check below if you have had any of the following diseases:

Heart Problems (chest pain, irregular heartbeat, etc.)

Respiratory Problems (shortness of breath, cough, etc.)

Urinary Tract Problems (pain, discomfort, red urine)

Skin Problems (rashes, dryness, rosacea)

Musculoskeletal Problems (arthritis, joint pain)

Neurological Problems (numbness, weakness, paralysis)

Psychiatric Problems (depression, anxiety)

Chronic Fever, Unexpected Weight Gain, Fatigue

Ear/Nose/ Throat (hearing loss, sinus or sore throat)

Endocrine Problems (diabetes, thyroid disease)

High Blood Pressure

Visual Health

Please check below if you have experienced any of the following:

Blurry Vision

Dry Eyes / Watery Eyes

Double Vision

Floaters, Flashing Light

Headaches

Red Eyes

Light Sensitivitiy

Eye Pain

Waviness in Vision

Loss of Peripheral Vision

Color Vision Loss