Glaucoma Questionnaire

Continue
* indicates a required field
Do you have a family history of:
Do you have any lung diseases:
Do you have any heart problems:
Have you ever had a stroke?
Do you have low blood pressure (Below 90/60)?
Do you get migraines?
Have you ever had a blood transfusion?
Do you have any bleeding disorders?
Do you have kidney disease?
Do you use any steroid medications? (nasal spray, inhalers, skin creams, injections, eye drops, oral)
Have you ever had any trauma or injury to either one of your eyes? (Had a black eye before)
Have you ever had laser or surgical eye treatment?
When you go outside do the tips of your finger, toes, nose, or ear turn blue or white in the cold? (Raynaud’s)
Consultation
The best way to contact me is:
Do you give Marietta Eye Clinic consent to reach out via Text Message?

All Glaucoma Center Services