Myopia Risk Questionnaire
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Pediatrician
Pediatrician's Phone Number
Please enter a valid phone number.
Is the patient taking any vitamins or other nutritional supplements?
Please Select
Yes
No
If Yes please list
Does the patient have a vitamin D deficiency?
Please Select
Yes
No
Unknown
Has the patient ever had an allergic reaction to atropine?
Please Select
Yes
No
Unknown
Is the patient allergic to any medical preservatives?
Please Select
Yes
No
Unknown
Approximate date of patient's last eye exam:
-
Month
-
Day
Year
Date
How many hours a day (in or out of school) does the patient spend on any digital device like a smartphone, tablet or computer?
What is the patient's usual posture while reading?
If the patient is required to do a lot of reading (more than 10 min at once) what time of day do they usually read?
During a typical day how many hours does the patient spend outside? (including recess)
When the patient reads on a digital device (smartphone/tablet/computer) what color background do they read on?
What time does your child go to bed?
How many nights a week does your child usually go to bed at approximately the same time?
At approximately what age did your child first start wearing eyeglasses or contact lenses?
Parent History
Has either parent worn, or do they currently wear eyeglasses or contact lenses?
Mother
Father
Neither
Unknown
If yes at what age did Mother start wearing eyeglasses or contact lenses?
If yes at what age did Father start wearing eyeglasses or contact lenses?
Has either parent had refractive surgery?
Mother
Father
Neither
Unknown
Ethnicity of Mother
Ethnicity of Father
Sibling History
How many siblings does the patient have?
How many sisters?
How many brothers?
Do any siblings wear eyeglasses or contact lenses?
Please Select
Yes
No
At what age did sibling(s) star wearing eyeglasses or contact lenses?
Name of person completing this form:
First Name
Last Name
Relationship to patient
Please Select
Mother
Father
Grandparent
Legal Guardian
Other
Submit
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