Have you been diagnosed with glaucoma?
What is your vision acuity?
Date of Birth
Date Format: MM slash DD slash YYYY
What is your address?
State / Province / Region
ZIP / Postal Code
Have you had eye surgery in the last 3 months?
Have you had eye surgery in the last year?
Are you currently taking any medication for your glaucoma? (Yes, no) If yes, which medication?
Have you taken any medication for your glaucoma in the past? If so, which medication?
Do you have diabetes