*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 myopia

What is the child’s ethnic background?

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

Does 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

Southlake | 817-310-3989

Ft. Worth - 7th St. | 817-348-9090

Ft. Worth - Hulen | 817-346-7077

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.

EYEWORKS – Hulen

EYEWORKS – West 7th

EYEWORKS – Southlake

FW Specialty Surgicare