Glaucoma and Vision Screening Form
Please complete this form to help us assess your eye health and screen for potential glaucoma or vision issues.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any of the following risk factors for glaucoma? (Select all that apply)
Family history of glaucoma
High intraocular pressure
African, Hispanic, or Asian descent
Age over 40
Diabetes
Long-term steroid use
Other
Have you experienced any of the following symptoms recently? (Select all that apply)
Blurred vision
Eye pain
Halos around lights
Frequent changes in glasses prescription
Tunnel vision
No symptoms
Other
Please rate your current vision clarity (with glasses or contact lenses, if worn)
*
1
2
3
4
5
Visual Acuity (Screening Result)
*
Rows
Right Eye (OD)
Left Eye (OS)
Distance Vision
Near Vision
Intraocular Pressure (mmHg)
Rows
Right Eye (OD)
Left Eye (OS)
Pressure Reading
Did the patient pass the vision screening?
*
Yes
No (refer for further evaluation)
Additional Comments or Observations
Submit Screening
Should be Empty: