Sample Uveitis Questionnaire

Family History

These questions refer to your parents, grandparents, children, grandchildren, brothers, sisters, aunts, and uncles.

Has anyone in your family had:

• Cancer Yes No

• Diabetes Yes No

• Allergies Yes No

• Arthritis or rheumatism Yes No

• Syphilis Yes No

• Tuberculosis Yes No

• Sickle cell disease or trait Yes No

• Lyme disease Yes No

Has anyone in your family had medical problems of the:

• Eyes Yes No

• Skin Yes No

• Kidneys Yes No

• Lungs Yes No

• Stomach or bowel Yes No

• Nervous system or brain Yes No

Social History

Age (years) ______________________________________________

Current job ______________________________________________

• Have you lived outside of the United States? Yes No

• If Yes, where?

• Have you traveled outside of the United States in the past year?Yes No

• If Yes, where?

• Have you ever owned a dog? Yes No

• Have you ever owned a cat? Yes No

• Have you ever eaten raw meat or uncooked sausage? Yes No

• Have you ever been exposed to sick animals? Yes No

• Do you drink untreated stream, well, or lake water? Yes No

• Do you smoke cigarettes? Yes No

• How many alcoholic drinks do you have each day? ________________

• Have you ever used intravenous drugs? Yes No

• Have you ever taken birth control pills? Yes No

• Have you ever had a bisexual or homosexual relationship? Yes No

Personal Medical History

• Are you allergic to any medications? Yes No

If Yes, which medications?

Please list the medicines you are currently taking, including nonprescription drugs, such as aspirin, ibuprofen, acetaminophen, antihistamines, and heartburn medications.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medical History

Please list all eye operations you have had (including laser surgery) and the dates of the surgeries.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list all other operations you have had and the dates of the surgeries.

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Have you ever had any of the following illnesses?

• Cancer Yes No

• Diabetes Yes No

• Hepatitis Yes No

• High blood pressure Yes No

Have you ever had any of the following illnesses?

• Anemia (low blood cell counts) Yes No Maybe

• Pneumonia or pleurisy Yes No Maybe

• Tuberculosis Yes No Maybe

• Herpes (cold sores) Yes No Maybe

• Chicken pox Yes No Maybe

• Shingles (zoster) Yes No Maybe

• German measles (rubella) Yes No Maybe

• Measles (rubeola) Yes No Maybe

• Mumps Yes No Maybe

• Chlamydia or trachoma Yes No Maybe

• Syphilis Yes No Maybe

• Any other sexually transmitted disease Yes No Maybe

• Leprosy Yes No Maybe

• Leptospirosis Yes No Maybe

• Lyme disease Yes No Maybe

• Zika virus infection Yes No Maybe

• Histoplasmosis Yes No Maybe

• Candidiasis or moniliasis Yes No Maybe

• Coccidioidomycosis Yes No Maybe

• Sporotrichosis Yes No Maybe

• Cryptococcal infection Yes No Maybe

• Toxoplasmosis Yes No Maybe

• Ameba infection Yes No Maybe

• Giardiasis Yes No Maybe

• Toxocariasis Yes No Maybe

• Cysticercosis Yes No Maybe

• Trichinosis Yes No Maybe

• Whipple disease Yes No Maybe

• Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) Yes No Maybe

• Hay fever Yes No Maybe

• Allergies Yes No Maybe

• Vasculitis Yes No Maybe

• Arthritis Yes No Maybe

• Rheumatoid arthritis Yes No Maybe

• Lupus (systemic lupus erythematosus [SLE]) Yes No Maybe

• Scleroderma Yes No Maybe

• Reiter syndrome Yes No Maybe

• Colitis Yes No Maybe

• Crohn disease Yes No Maybe

• Ulcerative colitis Yes No Maybe

• Behçet disease Yes No Maybe

• Sarcoidosis Yes No Maybe

• Ankylosing spondylitis Yes No Maybe

• Erythema nodosum Yes No Maybe

• Temporal arteritis Yes No Maybe

• Multiple sclerosis Yes No Maybe

• Serpiginous choroidopathy Yes No Maybe

• Fuchs heterochromic iridocyclitis Yes No Maybe

• Vogt-Koyanagi-Harada syndrome Yes No Maybe