Test What is the main reason you are coming to see the Doctor? My child's vision prescription has gone up and I am concernedMy child's eyesight is getting worse and I want to understand why this is happeningMy child's vision is worsening and I want to talk to the doctor about doing something to stop itI read about myopia control treatments and would like to learn more about itI want to find a natural way for my child's vision from getting worseI 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?* Informative VideosExpertise on Myopia ManagementWord of mouthGreat Staff 😉Dr. Miglani's YouTube ChannelAnother Parents RecommendationInformative WebsiteOther: Please tell us about your child's vision currently with glasses It is fairly goodIt is bad and getting worseIt is ok but getting worse Have you noticed your child doing any of the following? SquintingComplaining of headachesHolding reading material closerUsing devices while eating dinnerDuring online learning having their face close to the screen Who else in the family wears glasses or contact lenses?* MotherFatherSisterBrotherGrandmotherGrandfatherN/A What is the vision prescription of any above family members to the best of your knowledge? Does your child have any brothers or sisters?* YesNo If your child has a brother or sister what are their ages? * 1-34-67-1011-1515-1818+ Does your child like to read?* YesNo How many hours a day does your child read?* Less Than 1 Hour1-2 Hours3+ Hours Does your child do well in school? (Are they at grade level with reading, etc.?) YesNoOther When your child is doing online schooling is natural sunlight coming through their room? YesNo Does your child spend time outside? If so how long?* Less than 1 Hour per week2-4 Hours per week4-6 Hours per week6+ Hours How often does your child play with other children outside? Less than 1 Hour per week1-2 Hours per week3+ Hours per week What outdoor activities or indoor sports does your child enjoy doing?* SoccerBasketballBaseball/SoftballVolleyballTennisRunninglaying CatchGoing For A WalkRiding A BikePlaying With Other ChildrenGoing To The ParkOthre How many hours of sleep does your child get per night?* 5-7 Hours7-9 Hours9+ Hours Does your child have their own smartphone or iPad?* YesNo At what age did your child start using smart devices (such as iPad, smartphone?* 1-34-67-9Other Does your child play video games on computer, iPad or a smartphone? If so how many hours. Less than 1 Hour per week1-2 Hours per week3-4 Hours per week5-6 Hours per week7+ Hours per week How much time does your child spend on electronic devices such as an iPad or smartphone daily?* Less Than 1 Hour1-2 Hours3-4 Hours5-6 Hours7 or more HoursOthers If your child is doing online schooling how much time are they spending on the computer for class?* Less Than 1 Hour2-3 Hours3-4 Hours5+ Hours Tell us how you manage your child’s screen time. My child puts down the devices the moment I ask them toI use the screen time option on the devices to control the amount of screen time usedMy child gives me difficulty when I ask them to reduce screen timeI am quite laid back about screen timeOther: Please tell us about your child’s posture They sit straight and hold reading material at a good distanceThey lean to one sideThey slouch when readingThey lay down when readingThey slouch when they walk Please use the following statements to describe the overall traits of your child. My child is really smart, works really hard, gets good grades.My child is very social & likes to spend time with parents & friendsMy child is shy, likes to spend time alone doing good things.I have high expectations for my child. Please tell us about the stress level of your child. Very little to no stressLittle bit of stressA lot of stress 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? * I want my child to be free of glassesI don't want my childs myopia to get worseI would like to prevent more serious problems later in lifeI want to give my child the best chance for a good education and career Have you searched for information about myopia progression online? If so what did you find interesting? * How did you find out about us - about Hoot Myopia Care and our Doctor? * Google SearchDoctor ReferralAn Existing PatientYouTube VideosGoogle ReviewsHoot Myopia Care Website
