NAME: ______

THE RETINA GROUP

UVEITIS – SPECIFIC QUESTIONNAIRE

This questionnaire is to obtain facts pertinent to your past and present health. Please ANSWER ALL QUESTIONS, DO NOT LEAVE ANY BLANK. If you are not sure, guess. This form is to be a part of your medical chart and will be kept COMPLETELY CONFIDENTIAL unless your express permission is obtained.

Directions: Please answer each question by circling the appropriate answer, either Yes or No.

Family History

(Including maternal and paternal grandparents, uncles, aunts, first cousins, mother, father, sisters and brothers) These questions refer to your family, NOT YOU. Questions about your own health will appear in a later section.

Has anyone in your family (not including you) had:

Tuberculosis / Yes / No
Arthritis or Rheumatism / Yes / No
Sugar diabetes / Yes / No
Allergies / Yes / No
Gout / Yes / No
Syphilis / Yes / No

Has anyone in your family had medical troubles of the:

Eyes / Yes / No
Skin / Yes / No
Kidneys / Yes / No
Lungs / Yes / No
Intestines / Yes / No
Brain / Yes / No
Any glands / Yes / No

Social History:

Have you ever lived out of the United States?
Where?______/ Yes / No
Have you ever lived in states other than Ohio?
Where?______/ Yes / No
Do you smoke? / Yes / No
Do you or have you ever taken birth control pills? / Yes / No
Have you ever eaten raw meat or hamburger? / Yes / No
Have you ever had a puppy (less than 3 yrs of age)? / Yes / No
Have you ever had a kitten (less than 3 yrs of age)? / Yes / No
Have you ever been exposed to sick animals? / Yes / No
Do you drink untreated stream or well water? / Yes / No
Have you ever used IV drugs? / Yes / No
Have you ever had bisexual or homosexual relationships? / Yes / No
Have you been exposed to the AIDS virus (HIV)? / Yes / No
Is your job harmful to your eyes?
How? ______/ Yes / No

NAME: ______

Personal Medical History

Have YOU ever had any of the following diseases/conditions?

Anemia / Yes / No
Amoeba Infection / Yes / No
Arthritis / Yes / No
Bechet’s Disease / Yes / No
Cancer / Yes / No
Candida or Moniliasis / Yes / No
Chicken pox / Yes / No
Chlamydia or Trachoma / Yes / No
Crohn’s Disease or Ulcerative Colitis / Yes / No
Cryptococcal Infection / Yes / No
Cysticercosis / Yes / No
Erythema Nodosa / Yes / No
German Measles or Rubella / Yes / No
Giardiasis / Yes / No
Gonorrhea / Yes / No
Hepatitis / Yes / No
Herpes / Yes / No
Histoplasmosis / Yes / No
High blood pressure / Yes / No
Leprosy / Yes / No
Leptospirosis / Yes / No
Lupus or Systemic Lupus Erythematosus / Yes / No
Lyme Disease / Yes / No
Multiple Sclerosis / Yes / No
Pemphigoid / Yes / No
Pleurisy / Yes / No
Pneumonia / Yes / No
Psoriasis / Yes / No
Reiter’s Syndrome/Ankylosing Spondylitis / Yes / No
Rheumatoid Arthritis / Yes / No
Sarcoid / Yes / No
Scleroderma / Yes / No
Shingles or Zoster / Yes / No
Syphilis / Yes / No
Temporal Arteritis / Yes / No
Toxocariasis / Yes / No
Toxoplasmosis / Yes / No
Tuberculosis or TB / Yes / No
Ulcers / Yes / No
Vasculitis / Yes / No
Whipples Disease / Yes / No

NAME:______

Have YOU had any of the following symptoms?

General Health

Chills / Yes / No
Fevers / Yes / No
Night sweats / Yes / No
Fatigue or tire easily / Yes / No
Poor appetite / Yes / No
Recent weight loss / Yes / No
Do you consider yourself healthy / Yes / No

Head

Frequent or severe headaches / Yes / No
Frequent or severe dizziness / Yes / No
Fainting / Yes / No
Numbness or tingling in your body / Yes / No
Paralysis in parts of your body / Yes / No
Seizures or convulsions / Yes / No

Ears

Hard of hearing or deafness / Yes / No
Ringing or noises in your ears / Yes / No
Frequent or severe ear infections / Yes / No
Painful or swollen ear lobes / Yes / No

Nose or Throat

Sores in your nose or mouth / Yes / No
Severe or recurrent nose bleeds / Yes / No
Frequent sneezing / Yes / No
Stuffed up nose / Yes / No
Sinus trouble / Yes / No
Persistent hoarseness / Yes / No
Tooth or gum infections / Yes / No
Sore throat / Yes / No
Dry mouth / Yes / No

Skin

Rashes / Yes / No
Skin sores / Yes / No
Photosensitivity (sunburn easily) / Yes / No
White patches of skin or hair / Yes / No
Loss of hair / Yes / No
Tick or insect bites / Yes / No
Painfully cold fingers / Yes / No
Severe itching / Yes / No

NAME: ______

Have YOU ever had any of the following symptoms?

Respiratory

Severe or frequent colds / Yes / No
Constant coughing / Yes / No
Coughing up blood / Yes / No
Pneumonia / Yes / No
Recent flu or viral infections / Yes / No
Wheezing/asthma attacks/shortness of breath / Yes / No

Blood

Frequent or easy bruising / Yes / No
Frequent or easy bleeding / Yes / No
Blood transfusion / Yes / No

Gastrointestinal

Swallowing trouble / Yes / No
Diarrhea / Yes / No
Bloody stools / Yes / No
Severe heartburn or ulcers / Yes / No
Jaundice or yellow skin / Yes / No

Bones and Joints

Stiff joints / Yes / No
Painful joints / Yes / No
Swollen joints / Yes / No
Red and hot joints / Yes / No
Stiff lower back / Yes / No
Back pain while sleeping / Yes / No
Muscle aches / Yes / No
Heel, foot, or ankle pain / Yes / No

Genitourinary

Kidney problems / Yes / No
Bladder trouble / Yes / No
Blood in your urine / Yes / No
Urinary discharge / Yes / No
Genital sores or ulcers / Yes / No
Prostatis / Yes / No
Testicular pain / Yes / No

NAME:______

General Information

What it your height ______ft ______in
What is your usual weight? ______lbs
What is your present weight? ______lbs
Have you lost more than 10 pounds in the last year? / Yes / No
Is this the first time you have had this same type of eye condition? / Yes / No
Has anyone else in your family had this same, or a similar condition? / Yes / No
Have you ever known anyone with a condition similar to yours? / Yes / No
Are you pregnant or plan to become pregnant? / Yes / No

______

Patient Signature

Current and Past Occupations:

Place Patient Photo here

Physician Initials ______

Date ______

The Retina Group, Inc1