mm_ttl Myopia Management Quiz Myopia Risk Assessment *DISCLAIMER: This quiz is not designed to constitute advice as to your visual health or, more particularly, to provide a diagnosis. An accurate diagnosis for vision problems and conditions can only be made by an eye practitioner following a complete eye examination. Myopia (nearsightedness) can cause serious eye conditions, especially later in life. If your child has myopia, fill in the quiz below and your eye doctor will contact you to discuss their risk of myopia progression and how it can be prevented. Parent’s or Guardian’s Name* First Last Home Phone*Cell/Mobile*Email* Child’s First Name* Age*Age when your child was first diagnosed with myopia Never diagnosed Younger than 5 5-10 10-15 16 and older What is the child’s ethnic background? Asian/Pacific Islander Caucasian African American Hispanic Which family members have myopia? Father Mother Brother Sister On average, how many hours per day does your child spend outdoors? Less than 30 minutes 30 to 60 minutes 1-2 hours More than 2 hours On average, how many hours per day does your child spend reading from a book, or looking at a computer, tablet, or cell phone screen? Less than 30 minutes 30 to 60 minutes 1 to 2 hours More than 2 hours When using a tablet or cell phone, or while reading a book does your child hold it less than 30 cms from their face? Yes No Does you consider your child a bookworm? Yes No Does your child experience eyestrain when working on the computer? Yes No If your child wears glasses, does he or she leave them on when reading? Yes No
Myopia Management Quiz Myopia Risk Assessment *DISCLAIMER: This quiz is not designed to constitute advice as to your visual health or, more particularly, to provide a diagnosis. An accurate diagnosis for vision problems and conditions can only be made by an eye practitioner following a complete eye examination. Myopia (nearsightedness) can cause serious eye conditions, especially later in life. If your child has myopia, fill in the quiz below and your eye doctor will contact you to discuss their risk of myopia progression and how it can be prevented. Parent’s or Guardian’s Name* First Last Home Phone*Cell/Mobile*Email* Child’s First Name* Age*Age when your child was first diagnosed with myopia Never diagnosed Younger than 5 5-10 10-15 16 and older What is the child’s ethnic background? Asian/Pacific Islander Caucasian African American Hispanic Which family members have myopia? Father Mother Brother Sister On average, how many hours per day does your child spend outdoors? Less than 30 minutes 30 to 60 minutes 1-2 hours More than 2 hours On average, how many hours per day does your child spend reading from a book, or looking at a computer, tablet, or cell phone screen? Less than 30 minutes 30 to 60 minutes 1 to 2 hours More than 2 hours When using a tablet or cell phone, or while reading a book does your child hold it less than 30 cms from their face? Yes No Does you consider your child a bookworm? Yes No Does your child experience eyestrain when working on the computer? Yes No If your child wears glasses, does he or she leave them on when reading? Yes No
