Anti-VEGF Preferences and Expectations Survey Questions
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1 Anti-VEGF Preferences and Expectations Survey Questions Q1: Are you? Male Female Q2: What is your age? Less than or more Q3: Which of these groups best represents your race or ethnicity? White (non-hispanic) Black or African American (non-hispanic) Hispanic, Latino/a or Spanish origin Asian Pacific Islander Multi-racial or bi-racial Q4: What is your primary diagnosis? Diabetic retinopathy AMD Vascular occlusion (CRVO/BRVO)
2 Q5: How would you rate your overall health, on a scale where zero is as bad as death and 10 is best possible health? Q6: How would you rate your eyesight now (with glasses or contact lenses on, if you wear them), on a scale from 0-10, where zero means the worst possible sight, as bad or worse than being blind, and 10 means the best possible eyesight? Q7: How much difficulty do you have reading ordinary print in newspapers (with glasses or contact lenses, if you wear them)? No difficulty at all A little difficulty Moderate difficulty Extreme difficulty Stopped doing this because of your eyesight Stopped doing this for other reasons or not interested in doing this Q8: Are you currently driving, at least once in a while? Yes, during daylight and non-daylight hours Yes, but only during daylight hours No, mainly because of eyesight No, mainly because of other reasons Never drove Q9: How much difficulty do you have driving during the daytime in familiar places (with glasses or contact lenses if you wear them)? No difficulty at all A little difficulty Moderate difficulty Extreme difficulty Q10: Which of the following statements best describes your preference for deciding on a treatment? I prefer to make the decision about which treatment I will receive
3 I prefer to make the decision about my treatment after seriously considering my doctor s opinion I prefer that my doctor and I share responsibility for deciding which treatment is best for me I prefer that my doctor makes the decision about which treatment will be used, but I want my doctor to seriously consider my opinion I prefer to leave all decisions regarding my treatment to my doctor, without input from me Q11: When making a treatment decision which factor is the MOST important? Best visual result Low number of complications/problems/side effects Cost Number of appointments in a year Food and Drug Administration (FDA) approval of the treatment (on-label use) My physician s recommendation Q12: When making a treatment decision which factor is the LEAST important? Best visual result Low number of complications/problems/side effects Cost Number of appointments in a year Food and Drug Administration (FDA) approval of the treatment (on-label use) My physician s recommendation Q13: What result do you expect from the treatment? The treatment will slow the deterioration of my vision The treatment will stop the deterioration of my vision The treatment will improve my vision Q14: Has your treatment so far exceeded your expectations, met your expectations, or failed to meet your expectations? Exceeded expectations Met expectations
4 Failed to meet expectations Waiting to see Q 15: Not including your appointment today, how many appointments have you had for the problem for which you are currently being treated? or more Q16: How many injections have you received? or more Q17: Which drug is currently being injected? Avastin Eylea Lucentis Steroid Not sure Q18: Has your doctor changed the medication that you are receiving during the course of treating this problem? Yes No Not sure Q19: Before your first injection, how afraid were you about getting the injection? Terrified
5 Very afraid Somewhat afraid Not very afraid Not at all afraid Q20: After the first injection, how afraid were you/will you be for the next injection? Terrified Very afraid Somewhat afraid Not very afraid Not at all afraid
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