1. How old are you?
   40 years or less    41 to 49 years    50 years or more
2. Does anyone in your immediate family have glaucoma?
   Yes    No
3. Do you have regular eye examinations?
   Yes    No
4. Has your eye doctor ever told you that you have high pressure in your eyes (intraocular pressure, IOP)?
   Yes    No
5. Is your ancestry
   African-American    Asian    European    Other
6. Do you have diabetes?
   Yes    No
7. Are you near-sighted?
   Yes    No
8. Are you far-sighted?
   Yes    No
9. Have you used corticosteroid drugs (such as cortisone or prednisone) over long periods of time?
   Yes    No
10. Have you had an eye injury?
    Yes    No
11. Do you have high blood pressure?
    Yes    No

Sources: