Self-Assessment  ·  Confidential  ·  No Login Required
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Medical Disclaimer

This tool is not intended to diagnose, treat, cure, or prevent any disease or medical condition. It is a self-reporting survey designed for product feedback and personal tracking purposes only. Results do not constitute a medical opinion and should not be used as a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified eye care professional — such as an ophthalmologist or optometrist — with any questions you may have regarding a medical condition or changes in your vision. If you experience sudden vision changes, seek medical attention immediately.

This assessment tracks changes in your central and peripheral vision over time. There are no right or wrong answers — just your honest experience today.

Section 1 of 6
Your Information
Section 2 of 6
Vision Quality Scales
Rate each from −10 (very poor) to +10 (excellent).
For the following, select which eye is more affected today.
Section 3 of 6
Amsler Grid Drawing
Instructions: Wear your reading glasses if you use them. Cover one eye at a time.
Tap each grid to open it full-screen, then hold your phone 6–8 inches from your eye and focus on the center dot without moving your eye.
  • Blue → Wavy or distorted areas
  • Red → Missing, blank, or dark areas
◉ Left Eye
Tap to Draw
Opens full screen
Tap grid to open full-screen
Wavy: 0/1600 Missing: 0/1600
◉ Right Eye
Tap to Draw
Opens full screen
Tap grid to open full-screen
Wavy: 0/1600 Missing: 0/1600
Hold phone 6–8 inches from your eye.  Focus on the center dot — do not move your eye from it.
Section 4 of 6
Contrast Sensitivity
Can you clearly see the letter inside each patch?
Section 5 of 6
Light & Color
Question 1
How sensitive are you to bright light today?
Not at all
Mild
Moderate
Severe
Debilitating
Question 2
Do colors appear different between your two eyes?
No difference
Slightly washed out
Noticeably duller
Colors seem wrong
Question 3
When driving or outside at night, do you see halos or starbursts around lights (streetlights, headlights)?
Question 4
When you move from a bright area to a dark one, how many minutes until your vision settles?
Normal: under 7 min  ·  Mildly delayed: 7–12 min  ·  AMD range: 12–20 min  ·  Severely delayed: 20+ min
0 min (instant)7 min12 min30 min (severe)
Estimated time: 5 min
Question 5
Does your vision temporarily blur and then clear when you blink? (a sign of tear film instability)
Question 6
Do you see floaters today?
Section 6 of 6
Overall & Changes
Question 1
Which eye(s) are affected?
Question 2
Have you noticed any changes since your last assessment?
Question 3
Are you currently using any Piera product?
Question 4 — Optional
Additional notes
Before You Submit
Privacy & Data Use

What we collect. This survey collects your name, email, phone, date of birth, and self-reported vision symptoms including Amsler grid drawings.

How we use it. Responses are used solely for product development and educational purposes by Piera. We do not use your data to diagnose, treat, or manage any medical condition.

This is not medical care. This survey is not a clinical assessment or substitute for professional eye care. Always consult a licensed ophthalmologist or optometrist for medical concerns.

How we store it. Your responses are stored in a private, access-controlled database. We do not sell or share your information without consent.

Your rights. You may request to view, correct, or delete your data at any time.

⚠️ This privacy statement is a placeholder pending legal review.

Please fill in all required fields (name, email, phone).
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