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Supporting people with aniridia and their Families

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Membership Form

The information provided will remain private and will not be passed on to anyone without your prior consent. The statistics acquired from all membership forms will help advance the understanding of aniridia and how it effects the members of the Aniridia Network International.

Todays date

Section A – Personal Details

Name:

Date of birth:

Adress

Town:

County/Region:

PostZip Code:

Country:

telephone:

email:

Section B – Membership Details

I would like to be put in contact with other people in my area

Yes
No

I would Like to be a National Contact for my country

Yes
No

If you have answered yes and would like to be put in contact with other people in your country and/or would like to be a National contact please ensure you have filled in your Country in the contact details.

Are you a member of the Aniridia Network email discussion group?

Yes
No

If Yes, what is your Yahoo ID?

If no, would you like to join?

Yes
No

If yes, please ensure you have filled in the email field in Section A.

Section C – Who has Aniridia?

Please select as many as appropriate

I have Aniridia
My Child(ren) have aniridia
How many?
My Partner has aniridia
There is aniridia in my extended family
How many?
My Friend has aniridia
My Student has aniridia
My patient(s) has aniridia
How many?

SECTION D - Specific Diagnosis?

The following section is about specific diagnosis. Filling in this section will help us create an accurate picture of membership base. This will help us focus our efforts in the most appropriate way and help us to attract fund and research. If you would like to submit the details of more than one aniridic, Please submit this form then fill in a new form with only name and the details on the other aniridic.

Name:

Date of Birth:

Gender:male female

Type of aniridia

Bilateral (both eyes)
Unilateral (One eye)

No visible iris
Some visible iris
Atypical Aniridia

Familial Aniridia (some family history)
Sporadic Aniridia (no family history)
WAGR (Wilms tumour, Aniridia, Genital abnormalities, Mental Retardation) ?
Gillespie Syndrome

Have you had genetic testing?
Result:

Visual Acuity (eg. 20/20 6/6 etc.)


Left eye:
Right eye:

Please describe your/ your child’s functional vision

Cataracts
left eye
right eye

Glaucoma
left eye
right eye

Keratopathy (cornea problems)
left eye
right eye

Strabismus (crosseyed, lazy eye)
left eye
right eye

Macular/foveal Hypoplasia
left eye
right eye

Nystagmus
left eye
right eye

Optic Nerve hypoplasia
left eye
right eye

Any refraction errors (nearsightedness, farsightedness, astigmatism etc)

Surgical procedures

Other