Risk Management



Uveitis – Specific History Form

UVEITIS – SPECIFIC HISTORY FORM

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.

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                                                                                                  Yes         No

Severe anemia                                                                                     Yes         No

High blood pressure                                                                            Yes         No

Sugar diabetes                                                                                      Yes         No

Allergies                                                                                                 Yes         No

Hay fever                                                                                              Yes         No

Asthma                                                                                                  Yes         No

Hives                                                                                                      Yes         No

Gout                                                                                                       Yes         No

Syphilis                                                                                                  Yes         No

Has anyone 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

Credits: The Uveitis-Specific History Form is based on a form developed by the Francis I. Proctor Foundation.

Social History

In what states have you lived? (Please list ages and the number of years in each different state)

                                                                                                                                                                                               

 

                                                                                                                                                                                               

 

Have you ever lived out of the United States?                              Yes         No

Do you take any drugs regularly?                                                    Yes         No

Do you smoke?                                                                                    Yes         No

Do you or have you ever taken Birth Control Pills?                     Yes         No

Have you ever eaten raw meats or hamburgers?                          Yes         No

Have you ever had a puppy (less than 3 yrs. of age)?                 Yes         No

If so, was it de-wormed?                                                                    Yes         No

Have you ever had a kitten (less than 3 yrs. of age)?                  Yes         No

If so, was it de-wormed?                                                                    Yes         No

As a child did you play in sandboxes frequented

by kittens or puppies?                                                                         Yes         No

Your Past History

Have you enjoyed good health previously?                                  Yes         No

Do you suffer from chronic disease?                                               Yes         No

Have you ever had any of the following conditions:

Cold sores                                                                             Yes         No

Tuberculosis                                                                         Yes         No

Pneumonia                                                                           Yes         No

Rheumatism                                                                         Yes         No

Arthritis                                                                                  Yes         No

Hay fever                                                                              Yes         No

Asthma                                                                                  Yes         No

Hives                                                                                      Yes         No

Severe tonsillitis                                                                   Yes         No

Streptococcal infection                                                      Yes         No

Severe persistent diarrhea                                                  Yes         No

Severe influenza                                                                  Yes         No

Sugar diabetes                                                                      Yes         No

Scarlet fever                                                                         Yes         No

Skin rashes                                                                            Yes         No

Pleurisy                                                                                  Yes         No

Parasitic infection                                                                Yes         No

Other severe illness                                                              Yes         No

Have you ever had rheumatic fever? If so, did you

Have any heart or kidney complications?                                     Yes         No

Have you ever had persistent unexplained fever?                        Yes         No

Were you ever treated for severe anemia?                                     Yes         No

have you ever had, or were you ever treated for syphilis?          Yes         No

Did a doctor ever treat you for a tumor or cancer?                      Yes         No

Have you had gonorrhea?                                                                 Yes         No

Has your strength been up to par for the last 5 years?                 Yes         No

Have you had bleeding from your mouth?                                    Yes         No

from your nose?                                                                          Yes         No

from your lungs?                                                                         Yes         No

from your stomach?                                                                   Yes         No

from your bowel or rectum?                                                      Yes         No

Do you bruise easily?                                                                          Yes         No

Have you been treated with X-rays?                                               Yes         No

Have you ever had any serious injuries?                                        Yes         No

Have you had any surgical operations?                                         Yes         No

If yes, please list them in order of occurrence:

Type of Operation                                                                               Date

 

                                                                                                                                                                               

 

                                                                                                                                                                               

 

                                                                                                                                                                               

 

                                                                                                                                                                               

 

 

Localized Past History

Head

Do you suffer badly from frequent severe headaches?       Yes         No

Do you often have spells of severe dizziness?                       Yes         No

Do you frequently feel faint?                                                    Yes         No

Do you have constant numbness or tingling in any

part of your body?                                                                      Yes         No

Was any part of your body paralyzed?                                  Yes         No

Have you ever had a fit or convulsion?                                  Yes         No

Have you ever had a head injury?                                          Yes         No

Ears

Do you have any constant noises in either ear?                    Yes         No

Have you ever had mastoid trouble?                                      Yes         No

Have you ever had an ear infection?                                      Yes         No

Nose and Throat

Have you ever had your tonsils or adenoids removed?       Yes         No

Do you have persistent hoarseness?                                        Yes         No

Are you often troubled with bad spells of sneezing?            Yes         No

Is your nose often stuffed up?                                                  Yes         No

Have you at times had bad nosebleeds?                                Yes         No

Do you suffer from a constantly running nose?                    Yes         No

Have you had sinus trouble?                                                    Yes         No

Have X-rays been taken of your sinuses?                              Yes         No

Dental

Have you had your teeth examined in the past year?         Yes         No

Have you had teeth X-rays in the past year?                        Yes         No

Were any teeth found to be abscessed?                                  Yes         No

Skin

Are you often bothered by severe itching?                             Yes         No

Does your skin often break out in a rash?                              Yes         No

Are you often troubled with boils?                                           Yes         No

Respiratory

Do you often catch severe colds?                                            Yes         No

Do you frequently suffer from heavy chest colds?              Yes         No

Are you troubled with constant coughing?                             Yes         No

Have you ever coughed up blood?                                          Yes         No

Do you cough up any materials?                                             Yes         No

Have you had a chronic chest condition?                              Yes         No

Did you ever live with anyone who had T.B.?                       Yes         No

Do you sometimes have severe, soaking sweats at night?  Yes         No

Do you have bouts of chills and fever?                                  Yes         No

Gastrointestinal

Do you suffer from frequent loose bowel movements?      Yes         No

Have you ever had severe bloody diarrhea?                         Yes         No

Biliary System

Have you ever had jaundice (yellow eyes and skin)?          Yes         No

Have you ever had serious liver or gallbladder trouble?      Yes         No

Do you have bilious attacks?                                                    Yes         No

Bones and Joints

Are your joints ever painfully swollen?                                   Yes         No

Have your joints ever been red in color

or hot to the touch?                                                                     Yes         No

Do your muscles and joints constantly feel stiff?                 Yes         No

Are you troubled with a serious bodily disability?                 Yes         No

Do you usually have severe pains in arms or legs?               Yes         No

Do pains in the back make it hard for you to keep

up with your work?                                                                     Yes         No

Do you have a stiff back?                                                         Yes         No

Do you have stiffness of muscle or joints after

inactivity or sleeping?                                                                 Yes         No

Genitourinary

Has a doctor ever said you have kidney

or bladder disease?                                                                      Yes         No

If yes to the above question, please explain:

                                                                                                                                                                                       

 

                                                                                                                                                                                       

Do you have to urinate more often than normal?                Yes         No

Have you ever passed blood in the urine?                              Yes         No

Do you have burning or pain when you pass your urine?   Yes         No

Have you ever had a discharge from the penis?                   Yes         No

Neuromuscular

Do you have a stiff back in the morning on awakening?    Yes         No

Do you have shooting or lightning pains?                               Yes         No

Are you constantly too tired and exhausted even to eat?   Yes         No

Are you frequently ill?                                                                Yes         No

Are you frequently confined to bed by illness?                     Yes         No

Are you always in poor health?                                                Yes         No

Present Illness

What is your height?                                                                                   ft.                           in.

What is your usual 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

 

X                                                                                                                             X                                                                            

Patient Signature

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