Genetics, AREDS Formula, and Wet AMD Risk Study
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
*
Weight
*
What is your ethnicity?
*
White
Black
Hispanic
Asian
Other
Primary Ophthalmologist
*
Do you have wet AMD in the right eye?
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Yes
No
What year was this diagnosed?
Skip if unknown
Do you have wet AMD in the left eye?
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Yes
No
What year was this diagnosed?
Skip if unknown
What is your smoking history?
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Never Smoked
Quit Smoking
Currently Smoker
Have you ever had genetic testing for macular degeneration?
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Yes
No
Not Sure
What year did you get tested?
Have you ever taken eye vitamins?
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Yes
No
Not Sure
Which eye vitamins?
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e.g. PreserVision, I-Caps AREDS
How much zinc is in each pill?
Skip if unknown
When did you start the eye vitamin?
*
How many times a day?
*
Are you still taking eye vitamins?
*
Yes
No
When did you stop the eye vitamins?
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When taking the eye vitamins, have you often missed 4 or more doses a week
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Yes
No
Do you take a supplement when you have a cold?
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Yes
No
Which one(s)?
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Do you take a pure zinc vitamin when you have a cold or for other reasons?
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Yes
No
I consent to the release of medical records regarding the diagnosis and treatment of my macular degeneration to Dr. Kaufman and the other macular degeneration study investigators. These records will not be shared with anyone. We need information from your eye doctor about your macular degeneration in order to enroll you in this study.
*
I Agree
Submit
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