How\'s your child\'s prescription

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Assessment

Assessment Form

Parent's Name

Child's Name

Email

Phone Number

How old is the child?

Is the child already nearsighted or myopic?
(wears correction to see better in the distance)?

If your child is myopic, at what age did your child start to wear a corrective prescription?

If your child is myopic, has the prescription been stable over the past 2 years?

Are the child's parents myopic?

How many hours does the child spend outdoors?
(including breaks or recess at school)

On average, how many hours per day does your child spend reading from a book, or looking at a computer, tablet, or cellphone screen?

what our patient's say

"My daughter went to see a different eye doctor for her first ever eye appointment, and it didn’t go well for her. I can see she is struggling to see (squinting, getting close to tv, etc). So I decided to find a pediatric optometrist, and I’m so happy to have found Madeira Optical! Dr. Stout was amazing with my daughter."

Kali K.
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