Glaucoma Self Evaluation

Do you have a family history of:*

Glaucoma Blindness (not related to glaucoma) Any severe eye disease besides cataracts or dry eyes

Do you have any lung diseases:*

Asthma? Bronchitis? Emphysema? COPD

Do you have any heart problems:*

Congested heart failure Coronary Artery disease Heart arrhythmia Ever had a heart attack

Have you ever had a stroke?*

Yes No

Do you have low blood pressure (Below 90/60)?*

Yes No

Do you get migraines?*

Yes No

Have you ever had a blood transfusion*

Yes No

Do you have any bleeding disorders?*

Yes No

Do you have kidney disease?*

Yes No

Do you use any steroid medications? (nasal spray, inhalers, skin creams, injections, eye drops, oral)*

Yes No

Have you ever had any trauma or injury to either one of your eyes? (Had a black eye before)*

Yes No

Have you ever had laser or surgical eye treatment?*

Yes No

When you go outside do the tips of your finger, toes, nose, or ear turn blue or white in the cold? (Raynaud’s)*

Yes No

Consultation

Yes, I would like to schedule a Consultation.

The best way to contact me is: *

Phone Email

Please provide us with your contact information:*