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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

Macular Degeneration

This 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.

Age-Related Macular Degeneration0 of 21 completed

1: Do you have dry or wet AMD? (This is very important, so if you aren’t sure, please call your clinic.)
Dry (atrophic age-related macular degenerationWet (neovascular age-related macular degeneration
2: Is your condition bilateral (both eyes) or unilateral (one eye)?
both eyes (bilateral)one eye (unilateral)
3: Which stage of AMD best describes your condition?
early (no visual symptoms)Intermediate (dim and/or distorted vision in affected eye)Advanced (areas of vision loss in affected eye)
4: Do you wear either prescription glasses or contacts?
yesno
5: How is the central vision in your best eye with lens correction?
fair-to-good central visionpoor central vision
6: Are your eyes overly sensitive to glare and/or bright light?
yesno
7: Do you take either the AREDS or AREDS-2 formulation of antioxidants and zinc?
yesno
8: Do you have one or more chronic conditions other than AMD (such as heart disease or diabetes)?
yesno
9: Do you get at least 20 minutes of productive exercise (equal to a brisk walk) every day?
yesno
10: Do you currently smoke tobacco?
yesno
11: Which generally describes your regular diet?
healthy (mostly high antioxidant salads, fruits, vegetables, lean meats and fish)unhealthy (mostly prepared foods high in cholesterol and saturated fats)moderately healthy/unhealthy
12: Are you experiencing feelings of depression that you can’t seem to shake?
yesno

13: How often do you engage in activities outside of the home (traveling, volunteering, participating in or attending events, etc.)?
Less than 2 hours a weekUp to 5 hours a weekMore than 5 hours a week
14: Do you live alone in your home or apartment?
yesno
15: Is there someone whom you consider to be your regular caregiver?
yesno
16: Do you drive or have access to transportation?
I drive.I don't drive. I DO have access to transportation.I don't drive. I DO NOT have available transportation.
17: Are you employed either full or part time?
yesno
18: How are you doing financially?
okayI need assistance.
19: Are you an active member of a support group, church, retirement community or do you have other opportunities to be with others?
yesno
20: Are you currently a student?
yesno
21: Do you live in the United States?
YesNo

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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