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Myopia Risk Assessment Form

(Only For Patient Wearing Minus Number)

Name*

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Guardian Mobile*

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DOB*

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Gender*

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Address*

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How many hours does your child/patient sleep in a day ?

Daytime (7am - 5pm)

This field is required

Night time (9pm - 6am)

Does your child/patient play Outdoor ?

This field is required

Does your child/patient use Laptop / Mobile / Tablet at Home ?

This field is required

Does your child/patient watch Television ?

This field is required

Does your child/patient have to use Andriod Tablet / I pad in school ?

This field is required

Does your child/patient use glasses ?

This field is required

Select Eye Glasses Power

OD (Right Eye)

Spherical Power
Cylindrical Power
Axis

OS (Left Eye)

Spherical Power
Cylindrical Power
Axis

Prescription/Eye Glasses Power

At what age there was Onset of Myopia ?

Is there any family history of wearing glasses ?

This field is required

Is child/patient Posture Incorrect while Watching TV or Reading book ?

This field is required

9891-555-701

Myopia Risk Assessment Form

How many hours does your child/patient sleep in a day ?

Does your child/patient play Outdoor ?

Does your child/patient use Laptop / Mobile / Tablet at Home ?

Does your child/patient watch Television ?

Does your child/patient have to use Andriod Tablet / I pad in school ?

Does your child/patient use glasses ?

OD (Right Eye)

OS (Left Eye)

At what age there was Onset of Myopia ?

Is there any family history of wearing glasses ?

Is child/patient Posture Incorrect while Watching TV or Reading book ?

What is the speed by which myopia is increasing ?

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