AMD Screener Form AMD Screener Form MACULAR DEGENERATION Are You At Risk? We Now Offer An Early Detection Screening. If you already have been diagnosed with age related macular this does not pertain to you. The macula is the central area of the retina, the delicate tissue in the back of the eye. A normal macula allows you to see fine details for activities like reading and driving. Age-related macular degeneration (AMD) is the leading cause of severe vision loss in people 50 years of age or older in the United States. The risk increases with time. At age 60, approximately 1 in 10 people have signs of AMD. By age 75, this increases to 1 in 3. In most people, AMD causes only gradual changes in vision over many years. However, in some cases, AMD changes more rapidly and causes severe vision loss in just a few months. While there is no cure, AMD can be slowed down with diet and lifestyle changes. Nutritional supplements are also recommended in some cases. Risk Factors Self-Test: Are you 50 years of age or older? * Yes No Do you have someone in your family with AMD? * Yes No Are you Caucasian (white)? * Yes No Do you smoke? * Yes No Are you overweight? * Yes No Do you have high blood pressure or cholesterol? * Yes No Do you have poor night vision? * Yes No If you answered yes to 3 or more questions, you have a greater risk of developing AMD. Dark adaptation—the recovery of vision when going from bright light to darkness—is relatively quick in healthy eyes, but can be incredibly slow in eyes with AMD. Fishbaugh Family Eyecare offers the AdaptDx® test to measure dark adaptation. This 5-10 minute, non-invasive test can help detect AMD 3 to 4 years before it can be detected by normal methods. This screening test is not covered by Medicare, Medicaid, or commercial insurance and will cost you $50 today if we perform it. You will not need to be dilated for the test. If you are interested, this can be done as part of your examination. The results will be reviewed by your doctor and discussed today. Choose one of the four choices below. I am at increased risk and would like the AdaptDx® test done today. Yes I would like to talk to the doctor about having the test done at a future visit. Yes I am not interested in having this test performed. No I am not interested because I have already been diagnosed with AMD. No Patient Name * Date * If you are human, leave this field blank. Submit
