Myopia Risk Questionnaire
Patient's Name
*
First Name
Middle Name
Last Name
Patient's Date of birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pediatrician
*
Pediatrician's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Is the patient taking any vitamins or other nutritional supplements?
*
Yes
No
If yes, list the name of the vitamins/supplements:
*
Does the patient have a Vitamin D deficiency?
*
Yes
No
Unknown
Has the patient ever had an allergic reaction to atropine?
*
Yes
No
Unknown
Is the patient allergic to any medical preservatives?
*
Yes
No
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?
*
What is your child's usual posture when reading?
*
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?
*
When your child is reading on a digital device (smartphone, tablet or computer), what color background do they read on?
*
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?
*
If already corrected, at approximately what age did your child first start wearing eyeglasses or contact lenses?
*
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PARENT HISTORY
Has either parent worn, or do they currently wear eyeglasses or contact lenses?
*
Yes
No
If so, which parent?
*
Mom
Dad
Both
At which age did mom start wearing eyeglasses or contact lenses?
*
At which age did dad start wearing eyeglasses or contact lenses?
*
Has either parent ever had refractive surgery (LASIK or PRK)?
*
Yes
No
Ethnicity of each parent
*
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SIBLING HISTORY
How many siblings does the patient have?
*
What is the sex of each of the siblings (ex: 1-F, 2-M)?
*
Do any of the siblings wear eyeglasses or contact lenses?
*
Yes
No
At what age did the sibling start wearing glasses?
*
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Name of Parent completing this form
*
First Name
Last Name
Parent Signature
*
Date of Form Completion
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: