Table

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

Basic information:
1Name:
2Age: Date of birth: Place of birth:
3Sex: Male  Female
4Who is your eye doctor?City/state/phone:
5Who is your regular doctor?City/state/phone:
Occupational information:
1What do you do for a living and what other jobs have you held in the past?:
2Has 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):
3Are you often around co-workers who smoke?
Environment/diet/habits:
1Do you live or have you ever lived at an unusually high elevation above sea level?
What level?
2Do you use or have you ever used a wood stove in your house?
3Do you eat more than average of any of the following foods: bamboo shoots, cassava, peaches, apricots, almonds, apple juice/sauce/seeds? Which ones?
4Are you a vegetarian or practise unusual eating habits or fad diets? Please describe
5Do you smoke?Pipe or cigarettes?
6If yes, how many years?How many packs per day?What brand of cigarettes (regular or light)?
7Are you often found around family members who smoke?
8Were there family members who smoked in the house when you were growing up?
9Are there currently other family members who smoke in your house? How much (packs per day)?
10Do 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)
11Do you exercise regularly?Have you always been physically active?
Past medical history:
1Do you wear glasses?
Are you near sighted or far sighted?
2Do you have any degree of colour blindness?
3Do you have a history of respiratory disease such as asthma, COPD, severe hay fever/dust allergies, tuberculosis, cancer? Please specify which one
4Do you have any heart problems?
5Have you ever been diagnosed with multiple sclerosis?
6Have 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
7Have you ever had urinary tract, bladder, or kidney infections? If so, how often, and how severe?
8Do you have any blood disorders such as anaemia, thalassemia, or abnormal clotting?
9Did you have a birth complication such as prematurity, caesarean section, or prolapsed cord?
10Were either of your parents alcoholic?
11What operations have you had, and did any of them require general anaesthesia?
12Have you ever had a major accident such as a fall or car accident, and did you sustain head injuries with loss of consciousness?
13List all major illnesses you have or have had
14List all medications and drugs that you take, including inhalers or oxygen
15List any medication you have taken in the past for an extended period of time, including chemotherapy, vitamins
16Are you allergic to any drugs? If so, which ones?
17Have you ever been tested for LHON? If yes, was the test positive or negative?
18Have 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?
19Describe the course of your disease so far
Family history:
1Are you married?
2How many children do you have?
3Do your children have any significant visual problems or wear glasses? Please describe

4Please 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:
5Is there anything else you feel is important to let us know that we have not asked you?
(Please use more paper if necessary)