Medical History Questionnaire Review of SystemsDo you presently have any problems in the following areas?YesNoEars, nose, mouth, throatCardiovascular (heart/blood vessels)Respiratory (lungs/breathing)Gastrointestinal (stomach/intestines)Genitourinary (genitals/kidney/bladder)Musculoskeletal (muscles/joints)Integument (skin)NeurologicalPsychiatric (anxiety, depression)Endocrine (hormones, glands)Hematologic/Immunological (blood)Seasonal allergies (hay fever, cedar etc)EyesYesNoLoss or blurred visionLoss of side visionDouble visionItching, burning, or dischargeRednessGritty feeling, dryness or tearingLight sensitivityEye pain or sorenessInfection of eyelashes or eyelidsGlare/halosPatient Ocular HistoryMark Yes or No to each questionYesNoAge-related macular degenerationLazy eye/Eye turnCataractsGlaucomaEye surgeryInjury to eyeInjury to eyePatient Medical HistoryMark Yes or No to each questionYesNoDiabetes mellitusHypertensionHigh cholesterolArthritisCancerAIDS/HIVList any conditions not mentioned aboveFamily HistoryMark Yes or No to each entry. If Yes, list which family member (mother, father brother, sister etc)Blindness Yes No Which Family Member Cataract Yes No Which Family Member Macular Degeneration Yes No Which Family Member Glaucoma Yes No Which Family Member Retinal Detachment Yes No Which Family Member Diabetes Yes No Which Family Member Hypertension Yes No Which Family Member Cancer Yes No Which Family Member Arthritis Yes No Which Family Member Others MedicationsList all current medications that you are currently usingMedication AllergiesList any allergies to medication (ie penicillin, sulfa) belowSocial HistoryDo you use tobacco products? Yes No How much per day? Do you drink alcohol? Yes No How often? Have you ever had a blood transfusion? Yes No When? Patient’s SignatureDate MM slash DD slash YYYY Physician’s SignatureDate MM slash DD slash YYYY If there are no changes in your history since your last visit, initial and date here