Table

Questionnaire used to obtain information about past medical and social history, smoking habits, and other possible disease related questions.

Basic information:
1	Name:
2	Age:	Date of birth:	Place of birth:
3	Sex: Male	Female
4	Who is your eye doctor?	City/state/phone:
5	Who is your regular doctor?	City/state/phone:

Occupational information:
1	What do you do for a living and what other jobs have you held in the past?:
2	Has your job(s) involved exposure to any chemicals or gases you are aware of which you would not normally have encountered in everyday life? (For example, exhaust fumes, paint, lead or mercury, dry cleaning solvents, mining, insecticide):
3	Are you often around co-workers who smoke?

Environment/diet/habits:
1	Do you live or have you ever lived at an unusually high elevation above sea level?
	What level?
2	Do you use or have you ever used a wood stove in your house?
3	Do you eat more than average of any of the following foods: bamboo shoots, cassava, peaches, apricots, almonds, apple juice/sauce/seeds? Which ones?
4	Are you a vegetarian or practise unusual eating habits or fad diets? Please describe
5	Do you smoke?	Pipe or cigarettes?
6	If yes, how many years?	How many packs per day?	What brand of cigarettes (regular or light)?
7	Are you often found around family members who smoke?
8	Were there family members who smoked in the house when you were growing up?
9	Are there currently other family members who smoke in your house?		How much (packs per day)?
10	Do you drink alcohol? How much? (How many drinks per day, week, year? One drink equals one beer, equals one martini, equals one glass of wine, equals one shot glass)
11	Do you exercise regularly?	Have you always been physically active?

Past medical history:
1	Do you wear glasses?
	Are you near sighted or far sighted?
2	Do you have any degree of colour blindness?
3	Do you have a history of respiratory disease such as asthma, COPD, severe hay fever/dust allergies, tuberculosis, cancer? Please specify which one
4	Do you have any heart problems?
5	Have you ever been diagnosed with multiple sclerosis?
6	Have you ever had any of the following:
	seizures
	numbness in arms or legs
	muscle weakness
	double vision
	difficulty with walking and coordination
	incontinence
	incurable headaches
	other neurological problems
	diabetes
	depression
	vitamin deficiency such as B12, thiamine, or folate
7	Have you ever had urinary tract, bladder, or kidney infections? If so, how often, and how severe?
8	Do you have any blood disorders such as anaemia, thalassemia, or abnormal clotting?
9	Did you have a birth complication such as prematurity, caesarean section, or prolapsed cord?
10	Were either of your parents alcoholic?
11	What operations have you had, and did any of them require general anaesthesia?
12	Have you ever had a major accident such as a fall or car accident, and did you sustain head injuries with loss of consciousness?
13	List all major illnesses you have or have had
14	List all medications and drugs that you take, including inhalers or oxygen
15	List any medication you have taken in the past for an extended period of time, including chemotherapy, vitamins
16	Are you allergic to any drugs? If so, which ones?
17	Have you ever been tested for LHON? If yes, was the test positive or negative?
18	Have you ever been diagnosed with LHON?
	If yes, how old were you when you first had symptoms?
	Did anything seem to trigger the symptoms to begin with?
	Does anything seem to make it worse or better?
19	Describe the course of your disease so far





Family history:
1	Are you married?
2	How many children do you have?
3	Do your children have any significant visual problems or wear glasses? Please describe
4	Please list as many family members as you can, their relation to you, and whether they have any significant visual problems that you are aware of.
	Name:	Relation:	Vision:




5	Is there anything else you feel is important to let us know that we have not asked you?
	(Please use more paper if necessary)