Data collection form
Name:	Age/sex:
Address:	Registration number:
Date:
Travel time:	Travel expenses:
Symptoms:
Painless DOV- yes/no Painful DOV - yes/no DOV for near- yes/no Pain- yes/no Headache- yes/no Redness- yes/no Colored halos- yes/no None Others-
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:
Occupation of head of family- Education of head of family- Housing- kaccha/pucca Number of people in the household- Per capita income Socioeconomic grade (as per Kuppusamy/Prasad classification)- Status in family- earning/nonearning Relation to head of family- Difficulty in navigation- yes/no Affordability of treatment- yes/no Knowledge about glaucoma- what is it? Do you know the importance of good compliance? Are you aware of its relationship with family history? Role of intraocular pressure? What is field loss? Is glaucoma blindness treatable?
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: