You will be asked questions about your / your child’s health and medical history, and other questions that will help to determine if you / your child may qualify to participate in the VISTA clinical trial. The questionnaire should take about five (5) minutes.  We will treat all personal and medical information you provide us as confidential.    

If your answers indicate that you or your child may qualify for the VISTA clinical trial, someone from our nursing staff will contact you within 48 hours to discuss the VISTA trial and conduct a brief medical history review.

1. What is your relationship to the potential study participant?

Myself

Parent of minor child

Legal guardian of minor child

Legally authorized representative of adult

Someone else

This is a required question. Please answer and resubmit.

1b. Please indicate your relationship to the potential study participant.

This is a required question. Please answer and resubmit.

2. Please indicate your gender, or, if you are the parent / legal guardian / legal representative, your child’s / loved one’s gender.

Male

Female

This is a required question. Please answer and resubmit.

3. What is the date of birth for you / your child / loved one?

This is a required question. Please answer and resubmit.

4. Please indicate which best describes you / your child / loved one:

Diagnosed with XLRP with confirmed mutation in the RPGR gene

Diagnosed with RP but have not received genetic testing to confirm my mutation

No diagnosis, but experiencing night blindness or tunnel vision

Neither a diagnosis nor experiencing symptoms

This is a required question. Please answer and resubmit.

5. Is your / your child’s / loved one’s vision between (20/32) and (20/200) in at least one eye, as determined on a standard eye chart?

Yes – at least one eye

Yes – in both eyes

No – in neither eye

Not Sure

This is a required question. Please answer and resubmit.