Save on XALATAN, and receive information and support from Vision Matters™. Call 1-800-711-2712 to register.
Learn more about Vision Matters™

Congratulations on taking control of your eye health and choosing to visit your doctor! The idea of high eye pressure and glaucoma may be scary, but you are taking an important step in taking control of your eye health. Talking to your doctor may be overwhelming. It is easy to forget the questions you want to ask, or the things you want to talk about. This appointment questionnaire is designed to help. Print it out and take it to your appointment.

The questionnaire includes:

• A detailed checklist of risk factors
• A section to list your symptoms
• A list of questions to ask your doctor if you are given a prescription
• A space for your notes and questions that you want to remember to ask
• Suggested questions to ask your doctor about XALATAN

This printout will help you remember what you would like to talk about so you can make the most of your doctor visit.

Print the questionnaire

1. If you have any risk factors in the list below, you may be at risk for high eye pressure or glaucoma. Check the box next to any risk factors you may have.
   I am over 60 years old.
   I have a family history of high intraocular pressure (eye pressure) and glaucoma.
   I am of African or Hispanic descent.
2. Take a moment to list any unusual visual problems or symptoms you may be experiencing, such as blurred vision, haloes around light, or headaches.
3. If your doctor prescribes medication, here are a few important questions to ask:
   • What medication will I be using?
   • How often should I use the medication?
   • What side effects may occur?
   • Will this medication interact with others I'm taking?
   • When do I need to come in for a follow-up visit?
4. In the space below, write down any questions you might have for your doctor so you don't forget to ask during your visit.