Myopia Risk Assessment Form
                    (Only For Patient Wearing Minus Number) 
                 
                
        
                
                
                
                
                
             
            
                
                    
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 ? 
                
                
             
            
            
                
                    
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 ?