Glaucoma Monitoring Log
Record glaucoma symptoms, eye-pressure or vision monitoring, medication use, and follow-up details for ongoing care.
Patient & Log Basics
Patient Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method
Phone
Email
Text Message
Mail
Other
Log Entry Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Eye Being Monitored
*
Left
Right
Both
Care Setting or Clinic Name
Glaucoma Status & Symptoms
Current glaucoma status
*
Please Select
No known glaucoma
Suspected glaucoma
Diagnosed glaucoma
Ongoing monitoring
Post-treatment follow-up
Other
Recent changes noticed
Eye discomfort or pain severity
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Symptoms experienced
Blurred vision
Halos around lights
Headache
Redness
Nausea
Sudden vision changes
Eye discomfort or pain
Other
Are your symptoms worsening, stable, or improving?
*
Worsening
Stable
Improving
Not sure
Blurred vision severity
1
2
3
4
5
Halos around lights severity
1
2
3
4
5
Overall symptom impact on daily activities
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Monitoring Measurements
Measurement Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Intraocular Pressure Readings (Left vs Right Eye)
Rows
Left Eye
Right Eye
IOP Reading 1
1
2
IOP Reading 2
3
4
Visual Field Test Result Notes
Optic Nerve / Eye Exam Notes
Missed Dose Count
Additional Observations
Medication & Treatment Use
Current eye drop or treatment name(s)
*
Prescribed dosing schedule
*
Taken as directed?
*
Yes
No
Not sure
Missed doses in the past 7 days
Morning dose
Midday dose
Evening dose
Night dose
No missed doses
Other
Side effects experienced
Eye irritation
Burning or stinging
Blurred vision
Redness
Dry eyes
Headache
No side effects
Other
Recent treatment changes recommended or started
Follow-up & Clinician Notes
Next follow-up appointment
Save Log
Should be Empty: