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Home » Eye Care Services » Myopia Management » Myopia Management Quiz

Myopia Management Quiz

Myopia Risk Assessment - New

*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
- 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
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

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West Orange Family Eyecare

414 Eagle Rock Ave, Suite 206A
West Orange, NJ 07052

Phone/Text: 973-325-0500

Fax: 973-325-0075

Email: westorangefamilyeyecare@gmail.com
(Do not send personal health information by email.)

Monday: 10:00 AM - 6:00 PM
Tuesday: 10:00 AM - 6:00 PM
Wednesday: 10:00 AM - 6:00 PM
Thursday: 10:00 AM - 6:00 PM
Friday: 10:00 AM - 6:00 PM
Saturday: 9:00 AM - 3:00 PM
Sunday: Closed

Old Bridge Eyecare

3384 U.S. 9
Old Bridge, NJ 08857

Phone/Text: 732-402-8800

Monday: Closed
Tuesday: Closed
Wednesday: 10:00 AM - 6:00 PM
Thursday: Closed
Friday: Closed
Saturday: 9:00 AM - 3:00 PM
Sunday: Closed

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Old Bridge Eyecare
3384 U.S. 9
Old Bridge, NJ 08857
https://www.westorangefamilyeyecare.com

West Orange Family Eyecare
414 Eagle Rock Ave, Suite 206A
West Orange, NJ 07052
https://www.westorangefamilyeyecare.com

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