Referral Form

Patient Information for Myopia Treatment

Name *

Age *

Optometrist or Pediatrician's Name *

What are you most concerned about? *

Pediatrician's name *

Worried about prescriptions increasing, child's glasses are becoming thicker, methods to slow myopia progression, etc

Does the patient currently wear glasses or contact lenses? *

When are the glasses/contact lenses worn? *

When was his/her first pair of glasses? *

During a typical day, how many hours per day does the child spend outside? *

During a typical day, how many hours per day does the child spend outside? *

Does the patient have a Vitamin D deficiency?*

Does the patient have a Vitamin D deficiency? *

Frequency of use of any computer or any digital handheld electronic devices (tablets, iPads, Smart Phone, etc): *

number of hours per day? number of days per week?

Does father and or mother wear glasses? *

What is the approximate strength of parents' prescriptions? *

Does any of the siblings wear glasses? *

What types of sports, musical instruments or hobbies does your child enjoy doing? *

About how many hours does the child sleep at night? *

Has your child EVER had an allergic reaction to Atropine? *

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