Questionnaire - Page 4(a) of 9
(1078 maximum possible questions)		 Last updated: Oct 09, 2008

THE ANALYST TM
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This section pertains to eye problems.
411.  Are you experiencing eye pain that is not caused by an injury? Include any burning, throbbing, aching or stabbing sensation.
Don't know
No
In the past only
Yes, in one eye only
Yes, in both eyes
412.  Visual acuity: Without corrective lenses, which answer best describes your vision?
Don't know
Nearsighted
Normal
Astigmatic
Farsighted
413.  Do you experience double vision?
Don't know
No, very rarely
Occasionally
Intermittently
Frequently, at least once a day or more
414.  Do you see halos around objects? Please answer 'Don't know' if seeing these halos is a result of laser surgery done on your eye/s.
Don't know
No
Yes, around bright lights
Yes, around objects
Yes, around bright lights and objects
415.  Have you noticed, or have others commented that your eyes seem to be bulging out or protruding?
No / don't know
Yes, but not due to hyperthyroidism
Yes, due to hyperthyroidism now resolved
Yes, but don't know why
Yes, due to current hyperthyroidism
416.  Have you noticed that one or both eyelids are harder to hold open, especially toward the end of the day? This is called ptosis.
Don't know
No, there is no drooping
Possibly
Noticeably with one eyelid
Noticeably with both eyelids
417.  Do your eyeballs (not eyelids) jerk or move involuntarily?
Don't know
No
Rarely
Occasionally
Yes, noticeably
418.  Have you had a problem with styes or chalazia on your eyelids? It may have also been referred to as a hordeolum.
Don't know
No
Isolated case/s in the past only
Recurrent problem
Current problem
419.  Vision - poor dark adaptation. Do you have difficulty seeing things when going from a light to a darkened room?
No / don't know
Mildly - can see well after very brief adjustment
Moderately - I need time to adjust
Seriously - can see only a little after a while
Severely - can see nothing at all
420.  Vision. Do you have general difficulty seeing, especially when the lights are dim?
No / don't know
Mild
Moderate
Serious
Severe - I can see barely anything or nothing
421.  Eye sensitivity to bright light. Do you feel sunlight is too strong for you, or need to wear sunglasses a lot?
No / don't know
Mildly - I occasionally have to shield my eyes
Moderately - I often need to shield my eyes
Seriously - I always need sunglasses
Severely - I can't stand bright sun at all
422.  Do you have any abnormal blind spots in your field of vision?
Don't know
No
The blind spot around optic nerve is enlarged
At least one elsewhere
Several
423.  Have you experienced any retinal detachments?
Don't know
No
Yes, due to a physical injury
Yes
Yes, more than one / once
424.  Have you had a problem with Cataracts?
No / don't know
In the past only, now resolved
Minor (juvenile, immature, early)
Moderate
Advanced, serious
425.  Have you had Glaucoma?
Never had it / don't know
No, but there is a family history
Past problem now resolved
Current possible / minor problem
Current major problem
426.  Have you had iritis?
Don't know
Never had it
In the past only
Current mild case
Current moderate or worse case
427.  Have you had uveitis?
Don't know
Never had it
In the past only
Current mild case
Current moderate or worse case
428.  Are you suffering from Macular Degeneration?
No / don't know
I suspect I might have it
Moderately
Seriously
Severely

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GLOSSARY

Blind Spots:  Blind spots (scotomas) are dark "holes" in the visual field in which nothing can be seen.

Cataract:  A steadily worsening disease of the eye in which the lens becomes cloudy as a result of the precipitation of proteins. Most cataracts are caused by the functions of the body breaking down. Eye trauma, such as from a puncture wound, may also result in cataracts.

Glaucoma:  A disease of the eye characterized by vision loss due to an increase in the pressure of fluid within the eye. This rise in pressure results from a build-up of aqueous fluid and leads to progressive damage to the optic nerve that transmits visual signals to the brain. Over time, glaucoma can lead to a gradual loss in peripheral vision. There are usually no signs that you're developing glaucoma until vision loss occurs.

Hordeolum:  A hordeolum is a bacterial infection of either the meibomian glands or ciliary glands (the glands of Zeis and Moll). If the latter are involved, the hordeolum is considered external and appears focal in nature. If the deeper meibomian glands are involved, the hordeolum is considered internal and is less circumscribed in appearance. Acute and chronic inflammation associated with hordeola, especially if improperly treated, may result in a granulomatous inflammation known as chalazia.

Iritis:  An inflammation of the iris of the eye.

Macular Degeneration:  Increasingly poor eyesight often accompanied by light sensitivity, distorted vision and a blank or dark patch in the center of vision.

Ptosis:  A drooping of the eyelid(s).

Retina:  A 10-layered, frail nervous tissue membrane of the eye, parallel with the optic nerve. It receives images of outer objects and carries sight signals through the optic nerve to the brain.



 


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