Arizona Glaucoma Specialists
( Tucson (520) 544-4393 Fax (520) 544-0098 Phoenix (480) 538-7075 Fax (480) 538-7952
Name:____________________________________ Date:___/___/____ Age/DOB:___________________________ Referred by:________________________________ Primary Care Physician:________________________________ Please fill out FRONT AND BACK of this page by checking or circling all that apply.
Is there a family history of Glaucoma? Glaucoma Suspect? Y N (Mother, Father, Brother, Sister, Other________)
Details (Dates, Doctors, etc.)
Decreased vision
Sharp – Dull – Constant – Intermittent – Upon awakening(morning) – Evening/Night Constant – Intermittent – Upon awakening(morning) – Day - Night Haloes around lights
Flashes of light
Fluctuating/Distorted vision
Double vision
Dryness/ Sandy feeling
Glare/Light Sensitivity
Drooping eyelid
Crossed eye/ Lazy eye
Excess tearing/ watering
Suspect - Open Angle - Closed Angle – Steroid Related – Childhood – Injury Related – Pigmentary - Other Glaucoma Surgery
Trabeculectomy w/ (Mitomycin, 5 FU) – Shunt – Other Glaucoma Laser
Iridotomy – Laser Trabeculoplasty (ALT, SLT) High eye pressure
Cataract Surgery/YAG Laser
Retinal detachment
Buckle – Laser Treatment – Cryo - Vitrectomy Macular degeneration/ hole
Diabetic eye disease
Retinal Vein/Artery Occlusion
Eye injury
Corneal Transplant
Glasses/Contact Lenses
Reading – Distance – Soft Lenses - RGP CURRENT EYE MEDICINES
Xalatan – Lumigan - Travatan(Z)
Alphagan P (brimonidine) 0.1% 0.15% 0.2%
Timoptic(XE) -Timolol(GFS) - Betimol - Optipranolol 0.25% 0.5%
Betagan(levobunolol) - Betoptic S - Ocupress 0.25% 0.5 %
Cosopt – Azopt - Trusopt
Pilocarpine 0.5% 1% 2% 4% (gel)
Diamox (Sequel) (acetazolamide) 250mg 500mg
Neptazane (methazolamide) 25mg 50mg
Are there any glaucoma medications you have taken previously? Y N _____________________________________ Are there any glaucoma medications you could not tolerate (allergies)? Y N _______________________________ What have your highest eye pressures been? (Pre-Treatment, Post-Treatment) RT___ LT___ Date ________Unknown Please list all other medications you currently are using (prescription, over-the-counter, herbs, vitamins, supplements): 1_______________________4______________________7______________________10________________________2_______________________5______________________8______________________11________________________3_______________________6______________________9______________________12________________________ Please list all other past surgeries (from birth to present): 1_______________________4______________________7______________________10________________________2_______________________5______________________8______________________11________________________3_______________________6______________________9______________________12_______________________ List all allergies: __________________________________________________________________________________ MEDICAL HISTORY
Diabetes (How many years?)
Breathing Problems or Treatments
Heart Problems or Treatments
Heart Attack – Arrhythmia – Irregular Heartbeat Blood Pressure Problems or Treatments
Stroke – Seizure, other Neurologic Problems
Depression – Psychiatric Problems or Disorders
Kidney Stones – other Genital/Urinary Disease
Currently Pregnant
Arthritis, Lupus, Thyroid, or Raynaud’s Disease
Skin Cancer – other Skin Disease
Sinus Problems – Ear/Nose/Throat problems
Ulcers – other digestive problems
Steroid Use
Inhalation – Oral Prednisone – Injection – Cream/Lotion Blood Loss – Anemia – Blood Transfusion
Social History
Occasional – 1/day – 2-3/day – 4+/day Do you smoke? Quit? When? _______________ Occasional – 1/2pack/day – 1pack/day – 1+pack/day
The above information is true and correct to the best of my knowledge.
Patient Signature: _________________________________________ Date: __________________
History Reviewed  No Changes  Additions as noted 

Technician Initials: _______
Doctor’s Signature: __________________________________________
Date: ___________________
TO BE FILLED OUT BY STAFF – Pulse_________ __________


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