Your Ortho-K Suitability Check Starts Here Email AddressSECTION 1: Your Vision & LifestyleThese questions help us understand your current vision needs and daily habits.What is your age (or the age of your child if you are enquiring for them)?7 - 25 years old25 - 40 years old40-60 years oldAbove 60 years oldHow would you describe your vision condition? (Select one or more)I have Myopia/Short-sightedness (I can see up close but not far away)I have Hyperopia/Long-sightedness (I can see far away but not up close)I have Presbyopia/Reading Issues (I struggle to with focusing on near tasks like reading menus and phones)I have Astigmatism (blurry or distorted vision at all distances)I'm not sureHow often do you wear glasses or contact lenses during the day?All the time, for everythingOnly for specific tasks (driving, screens, school)Rarely, but I know I need themI don't wear any vision correctionOn a typical day, how much time do you spend on digital screens (computer, phone, tablet)?Less than 2 hours2 to 4 hours5 to 8 hoursMore than 8 hoursHow active is your lifestyle with sports, fitness, or outdoor activities?Very active – I participate dailyModerately active – a few times a weekNot very active – most of my day is sedentaryHas an eye doctor ever diagnosed you with any of the following? (Select the most relevant)Dry Eye SyndromeSevere Eye AllergiesKeratoconus or other corneal issuesNone of the aboveIs there a family history of progressive nearsightedness (myopia) in your immediate family?Yes, one parent has myopia / short-sightednessYes, both parents has myopia / short-sightednessNoI'm not sureHave you noticed your / your child’s vision getting worse in the last year?Yes, my vision has been getting worseYes, my child/children’s vision (myopia) has been getting worseNo, my vision is about the sameNot sureWhat is your current glasses or contact lens prescription? (See “Sph” on your prescription/contact lens box)Low (less than -2.00)Moderate (-2.00 to -4.00)High (greater than -4.00)I don't know my prescriptionHave you ever been told you are not a good candidate for LASIK surgery?Yes, due to my ageYes, due to my prescription or thin corneasNo, I've never looked into itI am not interested in LASIKSECTION 2: Your Preferences & MotivationThese questions help us understand what you're looking for in a vision correction solution.What is/are your biggest pain point/s with wearing glasses / daytime contacts? (Select one or more)I find wearing glasses inconvenient or uncomfortable for everyday useI prefer not to wear glasses for aesthetic or professional reasonsI experience dryness or discomfort from wearing daytime contact lensesIt's a nuisance during sports such as running, swimming, or gymmingI’m exploring options that might help with my child’s myopia/short-sightednessWhich sentence below best describes how open you are to wearing Ortho-K lenses nightly to significantly reduce your dependence on glasses / daytime contact lenses?I strongly dislike wearing glasses/daytime contacts and I’m open to wearing these Ortho-K nightly.Glasses or daytime lenses get in the way during sports, swimming or daily routines - I’d consider Ortho-K if it fits my lifestyle.I’m comfortable with my current vision correction but curious about alternatives.I dislike wearing glasses/daytime contacts but I’m not open to wearing these custom contact lenses (Ortho-K) nightly.I’m happy with my current vision correction as it doesn’t bother me.What is your main motivation for considering a vision correction treatment like Ortho-K? (Select one or more)Freedom from glasses/contacts during the day for work, sports, or lifestyle.To slow the progression of myopia, especially for my child.I'm looking for a non-surgical and reversible option.I'm just exploring my options at this stage.What myopia control / management solutions have you / your child tried before? (Select one or more)Myopia control spectacle lenses - e.g. HOYA MiYOSMART, Essilor Stellest, etc.Atropine eye dropsMiSight daytime contact lensesMultifocal / bi-focal spectacle lensesOrthokeratology (Ortho-K) overnight lensesSingle-vision distance spectacle lenses (i.e. for driving/seeing the classroom whiteboard)Single-vision near spectacle lenses (i.e. for reading a book/near tasks)None of the aboveWhen it comes to a vision correction procedure, what is your biggest concern? (Select one or more)Safety and minimal potential side effectsReversible and non-surgicalPain or discomfort during the processWhether it will actually work for my specific visionThe cost and whether it's a good long-term value.Which statement best describes your next step?I am ready to book a consultation to see if I'm a suitable candidate for Ortho-K. 8I want to learn more about the process and success ratesI'm comparing Ortho-K to other options like special contact lenses or LASIK.I'm just gathering information for the future.TOTAL SCOREField GroupSubmit
