Family History
Has anyone in your family had the following diseases?
  • Diabetes
  • Arthritis
  • Syphilis
  • Tuberculosis
  • Sickle Cell disease or trait
  • Lyme Disease
  • Eye diseases
What ethnicity are you?
  • Caucasion
  • African American
  • Asian American
  • Latino American
  • Native American
  • Middle Eastern
Social History
  • Have you lived outside the USA
  • Have you ever owned a dog
  • Have you ever owned a cat
  • Have you ever owned cattle
  • Have you ever been exposed to sick animals
  • Have you ever drank raw milk
  • Have you ever drank untreated water
  • Do you smoke cigarettes
  • Do you drink alcohol
  • Have you used drugs recreationally
  • Have you ever used intravenous drugs
  • Have you ever used birth control pills
  • If you are a man, have you ever had sexual contact with another man
  • Have you ever had sex with prostitutes
  • Have you ever had a sexual partner who used intravenous drugs, was bisexual or homosexual who had sex with prostitutes or was a hemophiliac
Past Medical History
Have you ever had any of the following diseases?
  • Cancer
  • Diabetes
  • Hepatitis
  • Hypertension
  • Anemia
  • Pneumonia
  • Tuberculosis
  • Herpes
  • Chicken Pox
  • Shingles
  • German Measles (Rubella)
  • Mumps
  • Chlamydia
  • Syphilis
  • Any other sexually transmitted disease
  • Leprosy
  • Leptospirosis
  • Histoplasmosis
  • Candidiasis or Moniliasis
  • Coccidioidomycosis
  • Sporotrichosis
  • Cryptococcal Infection
  • Toxoplasmosis
  • Amoeba Infection
  • Giardiasis
  • Toxocariasis
  • Cysticercosis
  • Trichinosis
  • Whipple's disease
  • AIDS
  • Asthma
  • Allergies
  • Arthritis
  • Rheumatoid Arthritis
  • Lupus
  • Scleroderma
  • Reiter's Syndrome
  • Colitis
  • Crohn's Disease
  • Ulcerative Colitis
  • Behcet's Disease
  • Sarcoidosis
  • Ankylsosing Spondylitis
  • Erythema nodosum
  • Temporal Arteritis
  • Multiple Sclerosis
  • Serpiginous Choroidapthy
  • Fuch's Heterochromic Iridocyclitis
  • Vogt-Koyanagi-Harada syndrome
General Health
  • Chills
  • Fevers
  • Night Sweats
  • Fatigue
  • Poor appetite
  • Unexplained weight loss
  • other illness
Have you had any of the following in the time frame simliar to your eye problem?

Skin and Hair Problems
  • Rash
  • Blisters
  • Ulcers
  • Easily Sunburn
  • Dark Patches on the Skin
  • Lighter Patches on the Skin
  • Painfully Cold Fingers
  • Scaling of the Skin
  • Changes on the Finger or Toenails
Lung Problems
  • Constant Coughing
  • Couging up Blood
  • Shortness of Breath
  • Ashtma
  • Pneumonia
Heart Problems
  • Chest Pain
Genitourinary Problems
  • Blood in the Urine
  • Discharge or Pus
  • Pain during urination
  • Prostate Problems
  • Pain in the testicles
  • Bump, sores, or ulcers
  • Kidney Stones
Joint Problems
  • Painful Joints
  • Morning Stiffness
  • Muscle Aches
  • Back Pain
  • Heel Pain
  • Big Toe Pain
Digestive Problems
  • Abdominal Pain
  • Nausea, Vomiting
  • Difficulty, Swallowing
  • Blood in the Stool
  • Diarrhea
  • Constipation
  • Sores or Ulcers around the Anus
Brain and Nerve Problems
  • Headaches
  • Numbness / Tingling
  • Paralysis
  • Seizures
  • Psychiatric problems
  • Shooting Pains
Ear Problems
  • Deafness
  • Swollen ear lobes
  • Ear Infections
  • Severe Dizziness
  • Hearing noises in the Ears
Nose and Throat Problems
  • Sores in the Mouth or nose
  • Severe or recurrent nosebleeds
  • Frequent sneezing
  • Sinus Trouble
  • Persistent Hoarseness
  • Tooth or Gum Infections
Blood Problems
  • Frequent or Easy bruising
  • Received Blood transfusions