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Pediatric Myopia at Oculus Research

Oculus Research Garner, North Carolina

See if Your Child Qualifies!

Pediatric Myopia Pre-Screening Questionnaire

What is your child's Date of Birth?(Required)

Please specify DOB: DD/MM/YYYY

Has your child been diagnosed by a doctor with Myopia (Nearsightedness)?(Required)

Yes

No

Not sure

If you know your child’s prescription, please specify here:(Required)

Does your child currently wear glasses or contact lenses?(Required)

Yes, glasses

Yes, contact lenses

No

It was recommended, but my child does not currently wear them

Has your child ever been diagnosed with, or treated for, any binocular vision abnormalities (e.g., strabismus/crossed eyes, amblyopia/lazy eye)?(Required)

No

Yes

Not sure

Please Specify(Required)

Has your child used any products or therapies listed below, including the following?(Required)

Hard Contact Lenses for Myopia Control (Orthokeratology), Soft Contact Lenses for Myopia Control (MiSight, NaturalVue, Biofinity Multifocal, etc.), Spectacle Lenses for Myopia Control (HALT, DIMS, DOT), Atropine Eye Drops for Myopia Control

No

Yes

Please specify item(s) and date(s) of last use:(Required)

Has your child had any eye procedures, surgeries, or injections?(Required)

(Including, but not limited to: laser, LASIK, refractive surgery, cataract surgery, etc.)

Yes

No

Please specify what and when:(Required)

Does your child have any systemic health conditions, and if so, have they been stable for at least 30 days?(Required)

(Including, but not limited to: diabetes with glycemia out of range, thyroid malfunction, etc.)

No known systemic conditions

Yes, and stable for 30+ days

Yes, but NOT stable

Please Specify(Required)

Please Specify(Required)

Does your child have any significant or uncontrolled medical conditions that could affect study participation or safety?(Required)

Yes

No

Not sure

Please Specify(Required)

Please Specify(Required)

Parent Name(Required)

First Last

Child Name(Required)

First Last

Parent Email Address(Required)

Email Address Confirm Email Address

Parent Phone(Required)

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Oculus Research Locations

958 Vandora Springs Rd.
Garner, NC 27529
(919) 346-6945
info@oculusresearch.com

9650 Brier Creek Pkwy Suite 103
Raleigh, NC 27617
(919) 346-6945
info@oculusresearch.com

940 SE Cary Pkwy Suite 100
Cary, NC 27518
(919) 346-6945
info@oculusresearch.com

Mon - Fri: 8:00 AM - 6:00 PM
Sat & Sun: Closed

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