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Appointment Questionnaire

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.

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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

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

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 50 years old.

I have a family history of high intraocular pressure (eye pressure) and glaucoma.

I have high intraocular pressure.

I am of African descent.

I am Hispanic.

I have used steroids or cortisone for a long time.

I have had an eye injury.
Take a moment to list any unusual visual problems or symptoms you may be experiencing, such as blurred vision, haloes around light, or headaches.
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?
In the space below, write down any questions you might have for your doctor so you don't forget to ask during your visit.

Next: Glaucoma Simulator

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XALATAN is for the treatment of high eye pressure/intraocular pressure (IOP) in people with open-angle glaucoma or ocular hypertension.

Important Safety Information

Like all medicines, XALATAN can have side effects. These side effects are usually mild and tolerable and may include blurred vision, burning and stinging, eye redness, the feeling of something in the eye, eye itching, increased pigmentation (darkening) of eye color, or irritation of the clear front surface of the eye.

XALATAN may slowly cause darkening of the eye color due to increased brown color, darkening of the eyelid and eyelashes, and increased growth and thickness of eyelashes. Color changes can increase as long as XALATAN is administered and eye color changes are likely to be permanent.

The recommended dosage is one drop (1.5 µg) in the affected eye(s) once daily in the evening. If one dose is missed, treatment should continue with the next dose as normal.

There have been reports of bacterial keratitis associated with the use of multiple-dose containers of topical ophthalmic products.

This Web site is intended for residents of the United States only. The products discussed herein may have different product labeling in different countries.

The health information contained herein is provided for educational purposes only and is not intended to replace discussions with a health care provider. All decisions regarding patient care must be made with a health care provider, considering the unique characteristics of the patient.

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