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History forms
| Date____________ Name: ________________________, Project No: __________, DOB: _____ Male/female: ______ | ||
| History | RE | LE |
|---|---|---|
| Known glaucoma | Yes/no | Yes/no |
| Current ocular meds | ||
| Eye surgery | Trab/cataract - IOL/aphakia Others | Trab/Cataract - IOL/aphakia Others |
| Family history of glaucoma | ||
| Systemic history | ||
| Systemic medication | ||
| Duration of diabetes | ||
| Hypertension | Yes/no | |
| Heart disease | Yes/no | |
| Asthma | Yes/no | |
| Alcohol consumption | Yes/no | |
| Cigarette smoking | Yes/no | |
