MYOPIA PROGRAM PATIENTS ONLY

Birthdate (younger kids progress faster, so the sooner treatment is started, more likely for a successful outcome.)

Birth Sex (girls usually progress faster than boys.)

Last Eye Doctor:

Primary Care Physician:

Vitamins/Nutritional Supplements?

Vitamin D deficiency (may be a risk factor, low vitamin D, may be due to not enough outdoor time, another possible risk factor)

Has the patient ever had an allergic reaction to Atropine? (rare, but possible)

Are there any medical preservatives that the patient is allergic to? (Atropine is preserved w/ BAK)

During a typical day, how many hours per day does the patient spend outside? (more better than less)

How many hours per day (in or out of school) does your child usually spend on any digital device, i.e. smartphone/tablet/computer? (less better than more)

What is your child's usual posture when reading? (for example, sitting at a desk, in bed on their stomach, in bed on their back, etc?) (back better)

If your child is required to do a lot of reading (> 10 minutes at once), when do they usually do it? Morning, afternoon or night? (night better)

When your child is reading on a digital device, is the background black w/ white characters, or white w/ black characters? (black background is better)

What time does your child usually go to bed? (earlier than 9:30pm better)

How many nights per week does your child usually go to bed at approximately the same time? (consistency better)

Approximate date of last eye exam?

If already corrected, at approximately what age did the patient first start wearing eyeglasses or contact lenses?

Currently wear eyeglasses or contact lenses?

If yes, for what?

Any history of eye surgery, including refractive surgery (LASIK, PRK, etc)? (remind refr sx post-op they are still myopic and have not been "cured" by surgery)

Age first wore glasses or contact lenses, even if part time?

Siblings (M/F, how many?) - more myopic siblings increases risk

Ever worn eyelgasses or contact lenses?

If so, approximate age first worn?

Patient information

Billing information

Medical History

MYOPIA PROGRAM PATIENTS ONLY