Vision Loss Survey
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1. Have you been told by your eye doctor (ophthalmologist or optometrist) that you have an eye disease and it is causing you to have vision loss?

Have you been told by your eye doctor (ophthalmologist or optometrist) that you have an eye disease and it is causing you to have vision loss? No

Yes

If yes, what condition (eye disease) do you have?

2. Have you accessed low vision services before?

Have you accessed low vision services before? Yes

If yes, how long ago and where (CNIB, eye doctor, etc)?

3. Have you ever used any low vision devices (including store bought magnifiers)?

Have you ever used any low vision devices (including store bought magnifiers)? Yes

If yes, please specify the low vision devices you have used:

4. Are you still using the low vision devices?

Are you still using the low vision devices? Yes

If no, why did you stop using them?

5. What is the single biggest fear you have when it comes to living with your vision loss?

What is the single biggest fear you have when it comes to living with your vision loss?

6. What is the single biggest frustration you have when it comes to living with your vision loss?

What is the single biggest frustration you have when it comes to living with your vision loss?

7. What have you tried so far that hasn't worked?

What have you tried so far that hasn't worked?

8. If you had a magic wand, what would be the ideal solution for you?

If you had a magic wand, what would be the ideal solution for you?

9. If you could ask me one question about low vision or your vision loss, what would it be?

If you could ask me one question about low vision or your vision loss, what would it be?

10. Please feel free to provide the following information if you would like to receive our newsletter (four times a year) or be contacted about any upcoming events or latest news regarding eye research. All answers provided in this survey remain confidential. Thank you for time.
Dr. Ana M. Juricic

Please feel free to provide the following information if you would like to receive our newsletter (four times a year) or be contacted about any upcoming events or latest news regarding eye research. All answers provided in this survey remain confidential. Thank you for time. Dr. Ana M. Juricic Name:
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Vision Loss SurveyExit this survey

Vision Loss Survey
Exit this survey