Prevent Blindness Wisconsin: Survey - Contact Prevent Blindness Wisconsin

1.

Contact Information

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2.

I am

3.

I or a member of my family has (check all that apply):

	Glaucoma
	Age-related macular degeneration
	Cataract
	Diabetes
	Another eye problem (please specify in the comment box below)

4.

I am interested in:

	Vision screening for adults
	Vision screening for children
	Children's photoscreening
	Vision screening training and certification
	Workplace eye safety
	Vision rehabilitation
	Vision research for new cures and treatments
	Support groups for families coping with amblyopia

5.

I found out about this website from

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