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Get PH UPHS Form 2

_____ Date of last eye refraction _________________________________________________ Do you consider yourself in good health? Yes ____ No ____ If not, give details__________________________________________________________________ Do you wish to discuss any question with regards to your health, family history, sex or personal habit with a physician. Yes _____ No _______ Are you taking any medicines regularly? Yes ____ No ____ If so, what are these medicines?________________________________________.

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