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- Resources for Eyecare Professionals
- A Low Vision Rehabilitation Delivery Model

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Patients
Caregivers
Healthcare Professionals
- Resources for Eyecare Professionals
- A Low Vision Rehabilitation Delivery Model

Diabetes-related Retinopathy

This short questionnaire will provide what we need to know to assist you. Please respond to all questions, the personalization of your guide depends upon knowing as much about you as possible.

Diabetic Retinopathy0 of 20 completed

1: What kind of diabetic retinopathy do you have? (This is very important, so if you aren’t sure, please call your clinic.)
2: Is your diabetic retinopathy unilateral (affecting one eye) or bilateral (affecting both eyes)?
unilateralbilateral
3: Do you also have diabetic macular edema?
YesNo
4: Do you schedule comprehensive eye exams at least once a year?
YesNo
5: Do you wear either prescription glasses or contact lenses?
yesno
6: How is the vision in your best affected eye with lens correction?
7: Are your eyes overly sensitive to glare and/or bright light?
yesno
8: Do you get at least 20 minutes of productive exercise every day?
YesNo
9: Do you currently smoke tobacco?
YesNo
10: Are you currently a student?
YesNo
11: Are you experiencing feelings of depression that you can’t seem to shake?
YesNo

12: How often do you engage in activities outside of the home (traveling, volunteering, participating in or attending events, etc.)?
13: Do you live alone?
YesNo
14: Is there someone whom you consider to be your caregiver?
YesNo
15: Do you live in the United States?
YesNo
16: Are you employed full or part time?
YesNo
17: Are you age 65 or older?
YesNo
18: Are you an active member of a support group, church, retirement community or other opportunity to be with others?
YesNo
19: How are you doing financially?
20: What is your current transportation status?

Your Personalized Results

Congrats! You finished the survey. Now what? View your guide online below or click the button to download a PDF copy.

Download PDF

Your Personalized Results

Congrats! You finished the survey. Now what? View your guide online above or click the button to download a PDF copy.

Download PDF

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