KNOW YOUR RISK FOR ADVANCED AMD

Name

First Name

Last Name

Have you been diagnosed with any form of Age-related Macular Degeneration (AMD) *

Yes

No

What is your Smoking Status? *

Current Smoker

Past Smoker

Never Smoked

Do you have a family history of Age-related Macular Degeneration (AMD) (e.g. mother, father, siblings, or grandparents)? *

Yes

No

Do you have any of the following signs or symptoms of AMD? (check all that apply)

When you walk into a dark room your eyes take some time to adjust

Poor night vision

Trouble recognizing faces

Seeing a blank spot in the center of vision or Colors appearing to fade

None of the above apply