Interview Form

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Name of interviewer: ________________________________________________________________

Date and time of interview: ___________________________________________________________

Interviewee CDC ID number: __________________________________________________________

Ocular Syphilis Interview Form

December 2015

Duration of symptoms prior to diagnosis

When were you told you had syphilis? (month and year)

Month: ___________________ Year: __ __ __ __

How many days, weeks or months were there between when you began having eye problems and when you were told you had syphilis?

Days: ___________________ Weeks: ___________________ Months: ___________________

How many days, weeks or months were there between when you first sought care for your eye problems and when you were told you had syphilis?

Days: ___________________ Weeks: ___________________ Months: ____________________

In this time frame, did you see an eye doctor for your eye problems? Yes No

Could you give us the name of the eye doctor or the location of the clinic where you were seen?

_________________________________________________________________________________________

Did you see any other doctors for problems related to syphilis? Yes No

Could you give us the name(s) of the doctor(s) or the location(s) of the clinic where you were seen?

_________________________________________________________________________________________

Follow-up

What were the first eye problems you noticed?
___________________________________________________________________________________________

At any time, did you have any of these problems? I will list several:
Eye pain Details: ____________________________________________________
Red eye Details: ____________________________________________________
Blurry vision Details: ____________________________________________________
Some vision loss Details: ____________________________________________________
Can’t see out of 1 eye Details: ____________________________________________________
Can’t see out of both eyes Details: ____________________________________________________
Other problems Details: ____________________________________________________

Do you still have remaining vision problems? Yes No

If NO:

How many days, weeks or months were there between your treatment for syphilis and when your eye problems went away?

Days: ___________________ Weeks: ___________________ Months: ___________________

Other than the medicine you received for syphilis, did you require any additional medicine for your vision problem?

Eye drops: ______________________________________________________________________
Oral medicine: ___________________________________________________________________
Intravenous (IV) medicine: _________________________________________________________

If YES:

How many days, weeks or months has it been since you were treated for your syphilis?

Days: ___________________ Weeks: ___________________ Months: ___________________

Have you required any additional medication for your vision problem?

Eye drops: ______________________________________________________________________
Oral medicine: ___________________________________________________________________
Intravenous (IV) medicine: _________________________________________________________

Have you had to change any of your normal activities because of vision problems? Yes No

If YES: What sort of changes have been required? __________________________________________
_____________________________________________________________________________________

In the past month, how much has your eyesight prevented you from doing your normal activities? Would you say:

Not at all or hardly at all A fair amount A substantial amount

Medical and Vision History

Before your recent vision issues, did you wear glasses or contacts? Yes No

Did you visit an eye doctor at least once a year? Yes No

Have you ever taken medicine for an eye or vision related problem before? Yes No

If YES: Please specify: _________________________________________________________________

Do you take medicine on a regular basis currently? Yes No

If YES: Please list: _____________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Do you take herbal supplements, over the counter medicine or vitamins? Yes No

If YES: Please list: _____________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Have you had a friend or relationship partner who has had vision problems potentially related to syphilis? We won’t ask any names. Yes No

Do you have anything else to add? _____________________________________________________________

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)