The Ocular Immunology and Uveitis Foundation

Massachusetts Eye Research and Surgery Institution

Ocular Inflammatory Disease Review of Systems Questionnaire

Open and Print in PDF 

This is a confidential survey. Please respond to all questions by circling the proper answer.  Please bring with you to your appointment.

 

Name: _________________________________________________________

Date of Birth: ______________  Reason for Visit: _____________________________

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

Has anyone in your family had any of the following? 

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

 

Gout

YES

   NO

 

 

Has anyone in your family had medical problems listed below? 

Eyes 

YES

   NO

 

Skin 

YES

  NO

 

Kidneys 

YES

  NO

 

Lungs 

YES

  NO

 

Stomach or bowel 

YES

  NO

 

Nervous system or brain 

YES

  NO

 


 

Your SOCIAL HISTORY:

 Current job: ___________________   Employer:___________________

Have you lived outside the U.S.A.? 

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 had unpasteurized milk or cheese? 

YES

NO

Have you ever been exposed to sick animals? 

YES

NO

Do you ever drink untreated stream, well or lake water? 

YES

NO

Do you currently use tobacco products? 

YES

NO

Have you ever used recreational drugs injected in the vein? 

YES

NO

Have you ever had bisexual or homosexual relationships? 

YES

NO

Do you currently take or have you taken birth control pills in the last 5 years? 

YES

NO

       

 

Medications:

Are you allergic to any medications? 

YES

NO

If yes, which medications? _______________________________________________

Please list ALL EYE DROPS:

 Drug Name

 Dosage

Frequency/eye

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

         


 

Medications: LIST all Other MEDICATIONS:

Drug Name

 Dosage

Frequency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

PAST Medical/Surgical HISTORY:

Please List all Eye Conditions and Surgeries with dates:

Eye Medical Condition and Eye Surgeries

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list all other Medical History:

Medical Health Problems

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NonEye Surgeries

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever been told that you have the following conditions? 

Anemia (Low Blood Counts) 

YES

NO

Cancer 

YES

NO

Diabetes 

YES

NO

Hepatitis 

YES

NO

High Blood Pressure 

YES

NO

Pleurisy 

YES

NO

Pneumonia 

YES

NO

Ulcers 

YES

NO

Herpes (cold sores) 

YES

NO

Chicken Pox 

YES

NO

Shingles (Zoster) 

YES

NO

German Measles (Rubella) 

YES

NO

Measles (Rubeola) 

YES

NO

Mumps 

YES

NO

Chlamydia or Trachoma 

YES

NO

Syphilis 

YES

NO

Gonorrhea 

YES

NO

Any other sexually transmitted disease 

YES

NO

Tuberculosis (TB) 

YES

NO

Leprosy 

YES

NO

Leptospirosis 

YES

NO

Lyme Disease 

YES

NO

Histoplasmosis 

YES

NO

Candida or Moniliasis 

YES

NO

Coccidiomycosis 

YES

NO

Sporotrichosis 

YES

NO

Toxoplasmosis 

YES

NO

Toxocariasis 

YES

NO

Cysticercosis 

YES

NO

Trichinosis 

YES

NO

Whipple’s Disease 

YES

NO

AIDS 

YES

NO

Have you ever been told that you have the following conditions? 

Hay Fever 

YES

NO

Allergies 

YES

NO

Vasculitis 

YES

NO

Arthritis 

YES

NO

Rheumatoid Arthritis 

YES

NO

Lupus (Systemic Lupus Erythematosus) 

YES

NO

Scleroderma 

YES

NO


 

Have you ever had any of the following illnesses? 

Reiter’s Syndrome 

YES

NO

Colitis 

YES

NO

Crohn’s Disease 

YES

NO

Ulcerative Colitis 

YES

NO

Behcet’s Disease 

YES

NO

Sarcoidosis 

YES

NO

Ankylosing spondylitis 

YES

NO

Erythema Nodosa 

YES

NO


 

Have you ever had any of the following illnesses?  

Temporal Arteritis 

YES

NO

Multiple Sclerosis 

YES

NO

Serpiginous Choroidopathy 

YES

NO

Fuchs’ Heterochoromic Ididocyclitis 

YES

NO

Vogt-Koyanagi-Harada Syndrome 

YES

NO


 

Have you had any of the following symptoms in the past year? 

GENERAL HEALTH:  

Chills 

YES

NO

Fevers (persistent or recurrent) 

YES

NO

Night Sweats 

YES

NO

Fatigue (tire easily) 

YES

NO

Poor Appetite 

YES

NO

Unexplained Weight Loss 

YES

NO

Do you Feel Sick 

YES

NO

 

Have you had any of the following symptoms in the past year? 

HEAD:

Frequent or Severe Headaches 

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 AND THROAT:

Sores in Your Nose or Mouth 

YES

NO

Severe or Recurrent Nosebleeds

YES

NO

Frequent Sneezing

YES

NO

Sinus Trouble 

YES

NO

Persistent Hoarseness 

YES

NO

Tooth or Gum Infections 

YES

NO

 

SKIN:

Rashes 

YES

NO

Skin Sores 

YES

NO

Sunburn Easily (Photosensitivity) 

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

 

Have you had any of the following symptoms in the past year? 

RESPIRATORY:

Severe or Frequent Colds 

YES

NO

Constant Coughing 

YES

NO

Coughing Up Blood 

YES

NO

Recent Flu or Viral Infection 

YES

NO

Wheezing or Asthma Attacks 

YES

NO

Difficulty Breathing 

YES

NO

 

CARDIOVASCULAR:

Chest Pain 

YES

NO

Shortness of breath 

YES

NO

Swelling of your legs 

YES

NO

 

BLOOD:

Frequent or Easy Bruising 

YES

NO

Frequent or Easy Bleeding 

YES

NO

Have you Received Blood Transfusions 

YES

NO


 

GASTROINTESTINAL:

Trouble Swallowing 

YES

NO

Diarrhea 

YES

NO

Bloody Stools 

YES

NO

Stomach Ulcers 

YES

NO

Jaundice or Yellow Skin

YES

NO

 

BONES AND JOINTS:

Stiff Joints 

YES

NO

Painful or Swollen Joints 

YES

NO

Stiff Lower Back 

YES

NO

Back Pain while Sleeping or Awakening 

YES

NO

Muscle Aches 

YES

NO


 

Have you had any of the following symptoms in the past year?

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

Prostatitis 

YES

NO

Testicular Pain 

YES

NO

 

OTHER:

Are you Pregnant? 

YES

NO

Do you Plan to be Pregnant in the Future?

YES

NO