Eyethena New Patient

1
Organization ID
2
We ask you to fill out the onboarding survey as completely as possible. This will also us to personalize Eyethena for you. The survey will take about 15 minutes to complete. Upon completion, you will receive an email with Eyethena app download links and login instructions.
3
What is your name?* This field is required.
First Name
Last Name
4
What is your date of birth?* This field is required.
Date
Month
Day
Year
5
What is your email?* This field is required.
example@example.com
6
Did your ophthalmologist provide you with a code so that they could access your Eyethena tracking data?If so, enter the code below
7
If you did not receive a code from your ophthalmologist but are interested in sharing your Eyethena data, please enter your ophthalmologist's information below
Practitioner Name
Practice Name
Practitioner email (if available)
Practice Location (city)
8
What is your gender?* This field is required.
Male
Female
Non-Binary
9
Which of the following best describe you?* This field is required.We ask this question as some ethnic groups are at a higher risk for glaucoma. Please select all that apply.
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
Russian
Easter European
White or Caucasian
Multiracial or Biracial
A race/ethnicity not listed here
10
Do you have any of the following health conditions?* This field is required.Select all that apply
Allergies
Anxiety
Arthritis
Asthma
Auto-Immune Condition
Back Pain
Cancer
Celiac Disease
Chronic Fatigue/Low Energy
Depression
Diabetes
Eating Disorder
Fibroids/Ovarian cysts
Fibromyalgia
Gout
High Blood Pressure
High Cholesterol
IBS
IBD (Ulcerative Colitis, Crohn's Disease)
Kidney Disease
Liver Disease
Migraines/Headaches
Mental Health Condition
Obesity/Overweight
PMS/Menopausal Symptoms
Thyroid Condition
Skin Condition - Eczema, Psoriasis
Sleep Apnea
Other
No Other Health Conditions
11
Are you a smoker (nicotine)?* This field is required.
Yes, daily
Former smoker
Yes, occasionally
Have never smoked
12
How often do you use cannabis?* This field is required.
Daily
Weekly - not daily but at least once per week
Occassionally
I do not use cannabis
13
Is there a history of glaucoma in your family (genetic bloodline)?* This field is required.I
Yes
No
I'm not sure
14
Who in your family has or had glaucoma?* This field is required.Check all that apply
Mother
Father
Grandmother
Grandfather
Sister(s)
Brothers(s)
Other
I know someone in my family has glaucoma but I can't recall who
15
Is there a history of diabetes in your family (genetic bloodline)?
Yes
No
I'm not sure
16
Who in your family has or had diabetes?Check all that apply
Mother
Father
Grandmother
Grandfather
Sister(s)
Brothers(s)
Other
I know someone in my family has glaucoma but I can't recall who
17
Have you had a previous eye injury that resulted in surgery, hospitalization, or treatment of your eye in association with other injuries from an accident or assault?
YESNO
18
Which eye was injured?
Right
Left
Both
19
Was either eye left with permanent vision loss?
YESNO
20
Which eye was left with permanent vision loss?
Right
Left
Both
21
Have you had cataract surgery?(Surgery of the lens of your eye because you could not see well or it was causing glaucoma)
YESNO
22
On which eye?
Right
Left
Both
23
Where there any complications from your cataract surgery?(Surgery of the lens of your eye because you could not see well or it was causing glaucoma)
YESNO
24
Which eye had complications?
Right
Left
Both
25
What type of surgery?
Retina
Cornea
Both
Not sure
26
Have you had interventional eye surgery for glaucoma (other than laser surgery, which may have been at the same time as cataract surgery)?
YESNO
27
On which eye?
Right
Left
Both
28
Have you had any other eye surgeries (other than laser surgery, cataract surgery, or glaucoma intervention)?
YESNO
29
On which eye?
Right
Left
Both
30
Has anyone else in your family (genetic bloodline) had cataract surgery?Check all that apply
Mother
Father
Grandmother
Grandfather
Sister(s)
Brothers(s)
Other
I know someone in my family has glaucoma but I can't recall who
31
What type of glaucoma have you been diagnosed with?
Glaucoma suspect (at risk of developing glaucoma, preventative treatment and monitoring)
Regular Glaucoma or Open-Angle Glaucoma
Pseudoexfoliation Glaucoma
Narrow Angles or Shallow Chambers
Combination of Narrow Angles and Open-Angle Glaucoma
Not sure
32
Which eye has Shallow Chambers?
Right
Left
Both
Not Sure
33
Have you had Laser Iridotomy to prevent an acute glaucoma attack?
YESNO
34
Which eye?
Right
Left
Both
35
When were you diagnosed with glaucoma?
Recently - in the last three months
This year - 4 to 12 months ago
2 to 5 years ago
Over 5 years ago
Not sure
36
How are you feeling about your diagnosis?
Anxious
Confident
Fearful
Confused
Other
37
Do you have financial concerns about the monitoring and treatment of your glaucoma?
YESNO
38
Are you visually impaired due to glaucoma?
Yes, right eye
yes, left eye
yes, both eyes
No, I am not visually impaired
39
Are you visually impaired due to a non-glaucoma issue?
Yes, right eye
Yes, left eye
Yes, both eyes
No, I am not visually impaired
40
Do you know if you are far-sighted?
Yes, right eye
Yes, left eye
Yes, both eyes
No, I am not far-sighted
I'm not sure
41
Do you know if you are near-sighted?
Yes, right eye
Yes, left eye
Yes, both eyes
No, I am not near sighted
I'm not sure
42
Are you currently using an at-home device to monitor your IOP
YESNO
43
Are you interested in participating in research studies to further our understanding of glaucoma?
YESNO
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