AZOOR Statistical Data

Welcome to My Survey

Hi There! Thank you so much for clicking into this survey. The information we receive from patients like you is ESSENTIAL to our ability to work with leading edge doctors and researchers to find a cure. As you know, very little is known about AZOOR because it's such a rare disease. So by providing your statistical diagnosis data you are helping to provide important metrics that can help us understand more about the disease. Please know that your information is ONLY used for the purposes of research specifically related to AZOOR.

Thank you again for providing your response to this very important survey,

Liz Upchurch

The AZOOR Society

Question Title

* 1. Contact Information

Name

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Question Title

* 2. What is your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

Question Title

* 3. Are you male or female?

Male

Female

Question Title

* 4. On which continent were you born?

Africa

Antarctica

Asia

Australia

Europe

North America

South America

Question Title

* 5. What is your ethnicity? (Please select all that apply.)

American Indian or Alaskan Native

Asian or Pacific Islander

Black or African American

Hispanic or Latino

White / Caucasian

Prefer not to answer

Other (please specify)

Question Title

* 6. When were you first diagnosed with AZOOR?

Question Title

* 7. Which hospital diagnosed you with AZOOR?

Question Title

* 8. Who is the doctor that initially diagnosed you?

Question Title

* 9. Do you have AZOOR in one eye or both?

Just my Left eye

Just my Right eye

Both eyes

Other (please specify)

Question Title

* 10. May we contact you in the future for possible AZOOR research related purposes?

Yes