Take the

Assessment Form

Parent's Name

Child's Name


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

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