Vision Care Pathway Survey 2016

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

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* 1. What is your age group?

Under 18 years

19 - 35 years

36 – 49 years

50 – 64 years

65 – 79 years

80 years and over

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* 2. What vision condition(s) do you have? (check all that apply)

Age-Related Macular Degeneration (wet)

Age-Related Macular Degeneration (dry)

Bardet-Biedl syndrome

Choroideremia

Juvenile retinoschisis

Lebers congenital amaurosis

Retinitis pigmentosa

Stargardt disease

Usher Syndrome

Diabetic Retinopathy

Other (please specify)

Question Title

* 1. What is your age group?

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* 2. What vision condition(s) do you have? (check all that apply)

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* 3. In what year (approximately) were you diagnosed? (if you have more than one condition, please specify the year for each condition):