*DISCLAIMER: This assessment 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 a member of our care team will reach out to you to discuss their risk of myopia progression and how it can be prevented.

Child's Name*

First Last

Gender*

Male

Female

Other

Parent's or Guardian's Name*

First Last

Phone*

Email*

Pediatrician*

First Last

Pediatrician Phone*

Is the Patient taking any vitamins or other nutritional supplements?*

Yes

Please list the name of the vitamins/supplements:*

Has the patient ever had an allergic reaction to atropine?*

Yes

Unknown

Is the patient allergic to any medical preservatives?*

Yes

Unknown

Approximate date of the patient's last eye exam*

During a typical day, how many hours a day does the patient spend outside?*

How many hours per day (in or out of school), does your child usually spend on any digital device like a smartphone or computer?*

If your child is required to do a lot of reading (more than 10 minutes at once), what time of day do they usually read?*

What time does your child usually go to bed?*

How many nights per week does your child usually go to bed at approximately the same time?*

When your child is reading on a digital device (smartphone, tablet or computer), what color background do they typically read on?*

If already corrected, at approximately what age did your child first start wearing eyeglasses or contact lenses?*

What is your child’s usual posture when reading? (i.e. sitting at desk, in bed on stomach or back, etc.)*

Parent History

Has either parent worn (past or present) eyeglasses or contact lenses?*

Yes

Which parent?

Mom

Dad

Both

Has either parent ever had refractive surgery (LASIK or PRK)?*

Yes

Which parent?

Mom

Dad

Both

At what age did they start wearing eyeglasses or contact lenses?

Ethnicity of each parent

Sibling History

Do any of the siblings wear eyeglasses or contact Lenses?*

Yes

How many siblings does the patient have?

What is the sex of each of the siblings (1-F, 2-M)?

At what age did the sibling start wearing eyeglasses?