Online Risk Assessment Forms Please enter your contact information First Name Last Name Phone Email Birthdate GenderPlease select... Male Female Other Risk Assessment I acknowledge this risk assessment form isn't an eye exam. Do you have vision health insurance?Please select... Yes No Unsure What year was your last eye exam? If unknown, leave blank. Risk Assessment Questions Do you have blood relatives with glaucoma?Please select... Yes No Unsure Has a doctor treated you for or said you have glaucoma?Please select... Yes No Unsure Have you ever had an eye injury or eye surgery?Please select... Yes No Unsure Have you noticed a change in vision in the last 12 months?Please select... Yes No Unsure Do you have constant pain in or around your eyes?Please select... Yes No Unsure Are you black, Hispanic or Latino, and age 40 and older?Please select... Yes No Are you age 60 or older?Please select... Yes No Was your last dilated eye exam more than two years ago?Please select... Yes No Unsure Do you have diabetes?Please select... Yes No If you do have diabetes, was your last dilated eye exam more than one year ago?Please select... Yes No Unsure Questions? Would you like to sign up for our monthly FY-Eye Newsletter? Contact Information