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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.

Also why not support our petition to the Prime Minister to do more to help prevent AMD
   http://petitions.pm.gov.uk/supplementation/
 
 
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