MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.
VISION CHECK FORM
PLEASE MARK YOUR RESPONSE ON EACH LINE
Have you been bothered by:
Answer
Comments
Have you noticed a decrease in your vision
when you:
Answer
Comments
Signature of Patient or Patient's Legal Representative
655 Medical Center Dr. NE
Salem, Oregon 97301
503.581.5287
Fax 503.386.1377
mceyeclinic.com