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. 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 Do 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 Total risk scorehigh risk If your child shows consistent and recent signs of progressive myopia, it is critical that you schedule a myopia management consultation with our office as soon as possible. At , we have the technology and expertise to evaluate your child's myopia and offer various treatment options. moderate risk If your child has been experiencing minor diopter changes, but engages in habits that may increase their refractive error, we can help. Our myopia management program not only treats myopia, but will also guide your child in developing better habits and vision strategies to slow or stop myopia progression in its tracks. low risk Even with no signs of progressive myopia, it's important to visit , who will monitor and ensure that your child's vision stays healthy. However, we encourage you to discuss ways to keep myopia from progressing at your child's next routine eye exam. Want to discuss your score? Leave us your info!Our team will contact you to discuss your results within 24-48 business hours. You can also call the office and ask them to check up your results as well.Parent’s or Guardian’s Name* First Last PhoneEmail Child’s First NameAge Δ
