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E Specialist Starred Items indicate Required Information Address each item below Your thoroughness in completing this report is essential for this patient to receive appropriate services Ocular History (e.g., prematurity, previous eye diseases, injuries, or surgeries) Age of Onset: History: Visual Acuity (VA) * IMPORTANT * If the acuity can be measured, complete this box using Snellen acuities or Snellen equivalents or NLP, LP, HM, or distance at which the patient sees the 20/200 letter. Wit.

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