Get Myopia Questionnaire

The Myopia Questionnaire is a valuable tool designed to gather important information about a person's vision and myopia history. This guide provides clear steps to assist you in completing the questionnaire accurately and efficiently online.

Follow the steps to fill out the Myopia Questionnaire with ease.

1. Click the ‘Get Form’ button to obtain the Myopia Questionnaire and open it for online completion.
2. Fill in the patient’s name in the designated section marked 'Patient: _______________________'.
3. Enter the current date in the 'Date: __________________' section to indicate when the questionnaire is being filled out.
4. Respond to each question by circling the answer that best applies to the patient, starting with family history. Carefully consider how many of the patient's parents are myopic and select 'No', 'One', or 'Both'.
5. Indicate the severity of the parents' myopia by circling 'No', 'One', or 'Both' for the question regarding how nearsighted the parents are.
6. Provide the age at which the patient was first diagnosed with myopia by selecting '< 5 years', '6 to 9 years', or '> 10 years'.
7. Next, assess the level of concern regarding the patient's myopia by circling 'Not', 'A little', or 'A lot'.
8. Estimate how quickly you perceive the patient’s vision is deteriorating by selecting 'Not', 'Slowly', or 'Quickly'.
9. Quantify the daily studying time in hours by choosing 'Very little', '1 Hour', or 'Greater than 1 hour'.
10. Assess the time spent reading for enjoyment by marking 'Very little', '1 Hour', or 'Greater than 1 hour'.
11. Indicate the amount of time spent using devices (such as a phone or computer) by circling 'Very little', '1 Hour', or 'Greater than 1 hour'.
12. Record how much time is spent outdoors, selecting from 'Very little', '1 Hour', or 'Greater than 1 hour'.
13. Answer how frequently distance vision appears blurry after close work by marking 'Never', 'Rarely', or 'Frequently'.
14. For the question about eyewear, circle all applicable options: 'Glasses', 'Contacts', or 'Ortho-k'.
15. Indicate whether previous myopia control methods have been employed by selecting 'Yes' or 'No'. If applicable, provide details in the space provided.
16. Use the Additional comments section to provide any additional information that may be relevant.
17. Once all necessary fields are completed, save your changes. You may then choose to download, print, or share the filled-out questionnaire as needed.

Start filling out the Myopia Questionnaire online today for effective vision management.