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Myopia Management Quiz
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Home » Myopia Management » Myopia Management Quiz

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 myopia
- Never diagnosed
- Younger than 5
- 5-10
- 10-15
- 16 and older
What is the child’s ethnic background?
- Asian/Pacific Islander
- Jewish
- 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

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Five Points Eye Care

698 S Milledge Ave
Athens, GA 30605

Phone: 706-543-2020
Fax: 706-549-6618

Monday: 8:00 AM - 5:30 PM
Tuesday: 8:00 AM - 5:30 PM
Wednesday: 8:00 AM - 5:30 PM
Thursday: 8:00 AM - 5:30 PM
Friday: 8:00 AM - 1:00 PM
Saturday: Closed
Sunday: Closed

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Five Points Eye Care
698 S Milledge Ave
Athens, GA 30605
Phone: 706-543-2020
https://www.fivepointseyecare.com

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