Myopia Risk Assessment

Myopia Risk Assessment

For the Standardized Patient Evaluation of Myopia Risk Assessment, please answer the following questions by checking the box that best represents your answer. Select only one answer per question.

​​​​​​​Note: Parents or guardians completing this form for a minor should answer the questions as if they were the patient.

Ethnicity

Gender
Both males and females show myopic progression during growth years, but females show a higher rate of progression at an earlier age.

Age of Myopia Onset

Parental Myopia

Time Outdoors per Week

Time Spent on Near Tasks​​​​​​​

Contact Information

Please complete the information below and our office will contact you to schedule a myopia evaluation.

Would you be interested in receiving information about myopia and more?

New or returning patient?

Click to see your Myopia Risk Assessment score results.

Myopia Risk Assessment Results

Thank you for completing the Assessment!

Your Score:

If your score is:

  • <9 Lower Risk

  • 9-14 Low Risk

  • 15-19 Moderate Risk

  • 20-23 High Risk

  • 24-28 Very High Risk


The Questionnaire is one tool we use to help assess your symptoms. No matter what you scored on the quiz, we take your overall eye health very seriously.

Thank you for taking our Questionnaire! While this isn't a true assessment regarding whether you have Risk for Myopia Management or not, many practices use questions like these to indicate patients most at risk for Myopia.

For more information about your mopia concerns, speak to your eye doctor at your next eye exam or you can schedule an appointment by calling us at .

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