Patient {{ $iPatientNo }}

(Kindly fill the relevant information or tick, as appropriate.)

Patient Initial

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Medical History (Tick appropriate option)

Duration of Primary Open Angle Glaucoma or Ocular Hypertension (years)

Co-morbid Conditions

Treatment (Tick any one)

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Efficacy assessment

Intraocular pressure (mm/Hg)

Optic nerve head examination findings

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Safety assessment *

Has the patient experienced any adverse event [AE] during the treatment period?

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