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Pink Eye (Conjunctivitis)
Stye & Chalazion
Flashes and Floaters
Dry Eye
Eye Allergies
Digital Eye Strain (Computer Vision)
Cataracts (Evaluation and Co-Management)
Glaucoma (Risk and Management)
Macular Degeneration (AMD)
Diabetic Eye Disease (Diabetic Eye Exams)
Contact Lens Intolerance and Fitting Issues
Corneal Abrasions and Foreign Body
Pterygium and Pinguecula
Keratoconus and Irregular Corneas
Uveitis (Iritis)
Corneal Dystrophies (Including Macular Corneal Dystrophy)
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QUIZ 2: Does your child have a vision problem?
Step
1
of
5
0%
Does your child squint or tilt their head when reading or watching screens?
(Required)
Yes
Sometimes
No
This field is hidden when viewing the form
Myopiasum-Q1
Does your child hold books, tablets, or toys very close or very far away?
(Required)
Very close
Very far
No
This field is hidden when viewing the form
Myopiasum-Q2
This field is hidden when viewing the form
Hyperopiasum-Q2
Have teachers or coaches mentioned your child having trouble seeing the board or focusing?
(Required)
Yes
Maybe
No
This field is hidden when viewing the form
Myopiasum-Q3
Does your child complain of headaches or eye strain after school or screen time?
(Required)
Yes
Sometimes
No
This field is hidden when viewing the form
Hyperopiasum-Q4
Does your child blink a lot, rub their eyes, or cover one eye to see?
(Required)
Yes
Sometimes
No
This field is hidden when viewing the form
Hyperopiasum-Q5
Does your child bump into objects or seem unusually clumsy?
(Required)
Yes
Occasionally
No
Do they prefer sitting close to the TV or hold their phone inches from their face?
(Required)
Yes
Sometimes
No
This field is hidden when viewing the form
Myopiasum-Q7
Do they avoid reading or homework that involves focusing up close?
(Required)
Yes
Sometimes
No
This field is hidden when viewing the form
Hyperopiasum-Q8
When was your child’s last eye exam?
(Required)
Within the past year
1–2 years ago
3+ years ago
Never
This field is hidden when viewing the form
Myopiasum-Q9
This field is hidden when viewing the form
Hyperopiasum-Q9
Would you like peace of mind knowing your child’s eyes are healthy and developing normally?
(Required)
Definitely
Maybe
No
This field is hidden when viewing the form
Myopiasum-Q10
This field is hidden when viewing the form
Hyperopiasum-Q10
This field is hidden when viewing the form
totalscore-myopia
This field is hidden when viewing the form
totalscore-hyperopia
