Myopia Management Parent Questionaire

What is the main reason you are coming to see the Doctor?*

My child's vision prescription has gone up and I am concerned
My child's eyesight is getting worse and I want to understand why this is happening
My child's vision is worsening and I want to talk to the doctor about doing something to stop it
I read about myopia control treatments and would like to learn more about it
I want to find a natural way for my child's vision from getting worse
I heard about Ortho-K lenses and want to see if my child is a candidate for them to control myopia

What influenced you to come here to our doctor at Hoot Myopia Care?*

Please tell us about your child's vision currently with glasses*

Have you noticed your child doing any of the following?*

Who else in the family wears glasses or contact lenses?*

How many hours a day does your child read?*

When your child is doing online schooling is natural sunlight coming through their room?*

Does your child spend time outside? If so how long?*

What outdoor activities or indoor sports does your child enjoy doing?*

Does your child have their own smartphone or iPad?*

At what age did your child start using smart devices (such as iPad, smartphone?*

Does your child play video games on computer, iPad or a smartphone? If so how many hours.

How much time does your child spend on electronic devices such as an iPad or smartphone daily?*

If your child is doing online schooling how much time are they spending on the computer for class?*

Tell us how you manage your child’s screen time.

My child puts down the devices the moment I ask them to
I use the screen time option on the devices to control the amount of screen time used
My child gives me difficulty when I ask them to reduce screen time
I am quite laid back about screen time
Other:

Please tell us about your child’s posture

Please use the following statements to describe the overall traits of your child.

Please tell us about the stress level of your child.

Please tell us which statements you agree with

My own screen time is very high and I feel guilty that I am setting a bad example for my kids.
Kids today are being overworked .
I realize I need to spend more time with my kids doing fun, relaxing things.
Kids today have too much stress and we need to find a way to help them cope.
I want to do everything I can to help my child become successful.

What questions do you have for the doctor?*

What are your expectations about myopia management & how it may affect your child?*

How did you find out about us - about Hoot Myopia Care and our Doctor?*

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Online Assessment for Parent