Patient Inquiry Form for Myopia Control

What are you most concerned about? 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 was your child’s last eye exam with an eye doctor? *

When was your child’s first pair of glasses prescribed? *

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

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

Additional comments