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?*YesNoWhen 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?*YesNoNot SureFrequency 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 glassesMother wears glassesBoth parents wear glassesWhat is the approximate strength of parents' prescriptions?*Does any of the siblings wear glasses?*YesNoNot applicableWhat 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?*YesNoNot SureNameThis field is for validation purposes and should be left unchanged.