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Age Related Macular Degeneration

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Survey






To help with our research into Macular Degeneration and its causes we would be most grateful if you would take a few minutes to complete this simple survey.

 
 
Please complete the form on behalf of either yourself or the person suffering from Macular Degeneration

What country do you live in 
Your Origins 
What is the colour of your  -  Hair    Eyes    Skin 
Do you suffer from Macular Degeneration.   No    Mild   Moderate   Severe
Age    Are you -    Male or Female
Do you smoke  per day Do you drink alcohol  units per week
(one unit is equivalent to one glass of wine)
Are you a Vegetarian  Yes No