Patient Information for Myopia Treatment Name* Age* Pediatrician's name* What are you most concerned about?* Worried about prescription keep increasing, child's glasses are becoming thicker, methods to slow myopia progression, etcDoes the patient currently wear glasses or contact lenses?* Yes No When are the glasses/contact lenses worn?* When was his/her first pair of glasses?* During a typical day, how many hours per day does the child spend outside?* Does the patient have a Vitamin D deficiency?* Yes No Not Sure Frequency of use of any computer or any digital handheld electronic devices (tablets, iPads, Smart Phone, etc):* number of hours per day? number of days per week?Does father and or mother wear glasses?* Father wears glasses Mother wears glasses Both parents wear glasses What is the approximate strength of parents' prescriptions?* Does any of the siblings wear glasses?* Yes No Not applicable What types of sports, musical instruments or hobbies does your child enjoy doing?* About how many hours does the child sleep at night?* Has your child EVER had an allergic reaction to Atropine?* Yes No Not Sure EmailThis field is for validation purposes and should be left unchanged.