Data collection form | |||
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Name: | Age/sex: | ||
Address: | Registration number: | ||
Date: | |||
Travel time: | Travel expenses: | ||
Symptoms: | |||
| |||
Duration of symptoms- | |||
Examination: | |||
Right eye | Left eye | ||
Best corrected visual acuity | |||
Intra-ocular pressure | |||
C:D ratio | |||
Gonioscopy | |||
Visual field loss | |||
Anterior segment | |||
Posterior segment | |||
Diagnosis: | |||
Treatment: | |||
Place of residence: Urban/rural | |||
Social history: | |||
| |||
Compliance of treatment: yes/no | |||
Family history of glaucoma: yes/no | |||
Attended eye clinic/eye check-up in past 2 years: yes/no | |||
Check-up was done by: ophthalmologist/optometrist | |||
The presentation of glaucoma: early/late | |||
Diagram for cup disc ratio: | |||