Donate Today

We need you to help save the eyesight of millions of people. The Eye on Vision Foundation accepts all donations, no matter how big or small. Every dollar makes a difference!

 

 

 

 

 

 

Visual Snow Particpant Request for Next Study PDF Print E-mail
Please email Prof, Goadsby and Dr. Schankin at? This e-mail address is being protected from spambots. You need JavaScript enabled to view it with the following information. If you already sent a brief "I'm interested" email, please RESEND with this information. Thank you so much!

Name

Address

Date of Birth (Day/Month/Year)

Telephone number

Willingness to be contacted for research

Indicating they are allowing us to keep the contact details solely for communication for research? it?s a European data protection thing?

?

Brief description of symptoms ? I know it is difficult but for an email yes or no to the other symptoms

?

Short description of visual symptoms in own words:

?

Visual snow: what type (chose one):

-????????? black and white (i.e. only black dots on white background, white dots on black background)

-????????? clear (i.e. color of the background)

-????????? flashing (i.e. always white, brighter than background)

-????????? colored

-????????? all of these

Other symptoms (yes or no)

-????????? After images

-????????? Trailing of images in the vision

-????????? Blue field entoptic phenomenon (i.e. white squiggly lines moving pulsating on the blue sky)

-????????? Floaters in vision

-????????? Colored clouds or waves with eyes closed

-????????? Flashes of light

-????????? Impaired night vision

-????????? Sensitive to? light

-????????? Tinnitus