Bethpage Visual Performance Pilot Study with EyePromie Vizual Edge Pro Enrollment Form

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* 1. Please share your contact information. We will use it to notify you if you are chosen for the study.

First and Last Name

Email Address

Phone Number

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* 2. Are you 18 or older?

Yes

No

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* 3. Do you take vitamins?

Yes

No

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* 4. Do you take a vitamin containing zeaxanthin, lutein, or Omega-3 fish oil?

Yes

No

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* 5. Which vitamin do you take containing zeaxanthin, lutein, or Omega-3 fish oil?

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* 6. Do you experience difficulty driving at night?

Yes

No

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* 7. Please describe your experience driving at night.

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* 8. Are your eyes sensitive to light?

Yes

No

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* 9. Do you have difficulty reading greens?

Yes

No

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* 10. Please describe your experience trying to read greens.