Medical Evaluation Report

*Your Name:

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Gene Type:

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*Country:

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*How is your central vision and peripheral vision ?

*Can you still manage your daily life independently ?

Do you mind telling your age and how long have you been diagnosed of RP ?

*Do you have cataract or glaucoma ?

*Do you have other chronic diseases like hypertension, diabetes or heart diseases ?

Other information about your condition you want to share ?

*How did you first hear about Restorerpvision.com ?

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In order to help you more efficiently, please attach to us recent medical reports/images, such as scans.

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