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 myopiaNever diagnosedYounger than 55-1010-1516 and olderWhat is the child’s ethnic background?Asian/Pacific IslanderJewishAfrican AmericanHispanicWhich family members have myopia? Father Mother Brother Sister On average, how many hours per day does your child spend outdoors?Less than 30 minutes30 to 60 minutes1-2 hoursMore than 2 hoursOn 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 minutes30 to 60 minutes1 to 2 hoursMore than 2 hoursWhen using a tablet or cell phone, or while reading a book does your child hold it less than 30 cms from their face?YesNoDoes you consider your child a bookworm?YesnoDoes your child experience eyestrain when working on the computer?YesnoIf your child wears glasses, does he or she leave them on when reading?YesNo
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