Wet AMD Patient Survey Wet AMD Patient Survey The Angiogenesis Foundation and AMDF created this survey to help people with AMD get better care and treatment. Please fill out this survey if you are receiving injections for wet AMD (or have someone assist you in filling out the survey). OK Question Title * 1. Please indicate your current age. OK Question Title * 2. In what state or U.S. territory do you live? Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (DC) Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming OK Question Title * 3. What is your gender? Female Male OK Question Title * 4. How long have you had wet AMD? OK Question Title * 5. How long did you experience vision symptoms before talking to your doctor? OK Question Title * 6. How frequently do you receive injections for wet AMD? About once a month About every other month Less often than every other month (Less than 6 times a year) I have injections whenever my doctor thinks they are necessary, but not at regular intervals. OK Question Title * 7. How important is it to you that you make it to every injection appointment? Extremely important Important Somewhat important Not that important I don’t know OK Question Title * 8. What has happened to your vision since you started receiving injections? My vision has stayed the same. My vision has improved. My vision has gotten worse. OK Question Title * 9. Have you ever missed an injection or taken time off treatment? Yes No Why OK Question Title * 10. Have you ever experienced any vision loss after missing an injection or taking time off treatment? Yes No I have never missed an injection OK Question Title * 11. What would losing your vision mean to you? Check all that apply. The loss of my ability to live independently. The loss of my ability to drive. The loss of my ability to do the things I love. Hardship for my relationships. The loss of my identity since my sight is a part of who I am. Significant mental and emotional distress. It would not really affect my life. OK Question Title * 12. Please check one of the following. My vision is my top health priority. My vision is a top priority, but not my highest. My vision is a not a top priority for me. OK Question Title * 13. Which of the following is the biggest challenge you experience regarding your treatment for AMD? Check all that apply. Getting to-and-from my appointments. Getting an appointment scheduled. Finding help for my fear and anxiety. Dealing with being tired from my injection schedule. Other (please specify) OK Question Title * 14. If you had a question about AMD outside of your eye appointments, where would you go to get the information you needed? Check all that apply. My eye doctor Other healthcare professionals (e.g., nurses, physician assistants, etc.) Materials provided by the doctor or hospital AMD Advocacy/Support Groups Family Friends Online/Internet Television Magazines Newspapers None of these Other (please specify) OK Question Title * 15. You are receiving treatments that can prevent blindness. If you could help others by spreading the word, would you be willing to do it? Yes No OK Question Title * 16. Put a check next to the following statements if you agree with them. You should have your eyes checked as soon as possible if you notice vision problems. If you have wet AMD, you need to have injections that can preserve your vision. If you’re getting injections, you have to stick to the recommended schedule - it’s critical for preserving your vision. OK DONE