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)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Oliver, Sara Elizabeth (CDC) |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |