We greatly appreciate your time to fill out this survey. By filling out this brief, anonymous form, you are helping us to build better educational resources and improve your care pathway. Thank you!!

* 1. What is your age?

* 2. What vision condition(s) do you have?

* 3. Duration of condition:

YOUR CURRENT CARE AND SERVICES

* 4. Which healthcare providers are part of your circle of care? (check all that apply)

* 5. What community services do you use to help with your condition?

* 6. How satisfied are you with your current vision care (healthcare providers, community services, treatments, etc.)

  0 1 2 3 4
0 (extremely dissatisfied) - 4 (extremely satisfied)

* 7. Do you feel you have adequate and timely access to: (check all that apply)

EDUCATION ABOUT YOUR CONDITION

* 8. How do you prefer to obtain information about your condition (check all that apply)

* 9. Have you ever been to any other educational events such as Vision Quest?

YOUR NEW IDEAS AND SUGGESTIONS

* 10. What services / resources do you wish were available to you, but are currently lacking?

* 11. What topics would you like MORE time to discuss with your doctor at appointments?

* 12. List two (2) questions that you think are KEY to ask the doctor at every eye appointment

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