Eye Disease and Patient Engagement Survey - AMD

BACKGROUND: PLEASE TELL US MORE ABOUT YOU

Thank you for participating in this survey about living with an eye disease, which will help us better understand your experiences and the associated burdens of vision loss and blindness. Data from this survey will be used to advance patient research and related vision health policies in Canada.

Please take your time to answer each question to the best of your knowledge. There are no correct or incorrect responses, and your information will be kept safe and, unless specified otherwise, anonymous. It will not be shared with any other individual or organization. If this survey is inaccessible to you, or if you are interested in sharing more information about your experiences, please feel free to reach out to Dr. Chad Andrews at candrews@fightingblindness.ca or over the phone at 416-360-4200 ext. 263.

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* 1. What eye disease are you living with? Please select all that apply.

Achromatopsia

Age-Related Macular Degeneration (Dry)

Age-Related Macular Degeneration (Wet)

Bardet-Biedl Syndrome

Chroroideremia

Diabetic Retinopathy

Glaucoma

Retinitis Pigmentosa

Stargardt Disease

Usher Syndrome

Uveitis

X-Linked Retinoschisis

Leber Congenital Amaurosis

Other (please specify)

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* 2. If your disease is inherited, have you undergone a genetic test to determine which genes are affected?

Yes

Other (please specify)

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* 3. Does your eye disease affect one or both eyes?

One

Both

Other (Please Comment)

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* 4. In what year, approximately, were you diagnosed with your eye disease?

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* 5. In what year were you born?

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* 6. What is your postal code? (enter a valid postal code—for example, A1A 2B2)

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* 7. Would you be interested in providing your name and contact information so that we can follow up and stay in touch with you? This means that your are revoking anonymity, but your information will not be shared and would only be used to facilitate future communications between you and Fighting Blindness Canada. If you would like to do this, please fill out the contact information below. If you would like to remain anonymous, please skip and click "next" at the bottom of this page.

First Name

Last Name

Email Address

Phone Number

Street Address

City/Town

Province/Territory