Respondent:________________________________________________________

Grade/Section:_____________________ Gender: ________

Age:______________________________
Address:___________________________________________________________

Directions: Place a check mark (√ ) on the space provided for your answer.

(Familial Predisposition)

QUESTIONS YES NO
1. Is there anyone among your family living with you at your
house who wears eyeglasses?
2. If YES, place a check mark (√ ) on your family member (s) living with you
whom you see are wearing eyeglasses.

Father’s Side:
__Father
__Grandfather
__Grandmother
__Uncle : How many? Please specify:____
__Auntie: How many? Please specify:____
__Cousin:
__Male: How many? Please specify:____
__Female: How many? Please specify:____

Mother’s Side:
__Mother
__Grandfather
__Grandmother
__Uncle : How many? Please specify:____
__Auntie: How many? Please specify:____
__Cousin:
__Male: How many? Please specify:____
__Female: How many? Please specify:____

Siblings:
__Male: How many? Please specify:____
__Female: How many? Please specify:____

QUESTIONS YES NO
 3. Do you frequently see them wearing eyeglasses even when
they are not reading?

(Computer)

QUESTIONS YES NO
1. Do you have a computer at home?
2. If YES, are you fond of using the computer at home?
3. If you don’t have a computer at home, then do you prefer
using computers located at your neighborhood’s internet
shops?
4. Do you feel any headache when you are too close to the
computer screen for a long period of time?
5. Are there situations where you seem to have difficulty in
seeing things clearly at a far away distance after using a
computer?
6. Are there situations where you seem to have difficulty in
seeing things clearly within a short distance after using a
computer?

Directions: Encircle the letter that best describe your answer.

7. How far away are you from the computer whenever you are using it?
(Note:  1 Ruler)

A. LESS THAN 20 INCHES

B. 20 INCHES

C. MORE THAN 20 INCHES

3 3
hours hours
QUESTIONS
and and
below above
8. How long do you use the computer in an average sitting?
1-3 3-6 7
times times times
QUESTIONS
in a in a and
week week above
9. How many times in a week do you use a computer?
 1-2 3-4 5
times times times
QUESTIONS a day a day and
above
10. How many times in a day do you use a
computer?

(Environment)

QUESTIONS YES NO
1. Do you prefer sleeping with the lights turned off?
2. Do you often stay outdoors more than you stay indoors?

If YES:
1 2
hour hours
QUESTIONS
and
above
3. How long do you stay outside?

(Television)

QUESTIONS YES NO
1. Do you have a television at home?
2. Do you like watching television?
3. Do you need to sit close to the television while viewing what
you are watching?
If YES in number 3:
4. Do you feel any eye strains when you are too close to the
television screen for a long period of time?
5. Are there situations where you seem to have a difficulty in
seeing things clearly at far away distances after watching
 television?
6. Are there situations where you seem to have a difficulty in
seeing things clearly within a short distance after watching
television?

If you answered YES in question # 2:

3 3
hours hours
QUESTIONS
and and
below above
7. How long do you watch television at an average sitting?

Directions: Encircle the letter that best describe your answer.

8. How far are you from the television when you are watching?

A. Less than 6 feet

B. 6 feet

C. More than 6 feet

 (Video Games)

QUESTIONS YES NO
1. Do you like playing any video games particularly games from
the computer?
2. If yes, place a check mark (√ ) on the space provided on your preferred
computer video game that you play:
Computer:
___Online games (e.g. DOTA, Counter Strike, Ragnarok, etc.)
___Offline games (e.g. Diner Dash, Plants vs. Zombies, Sims, etc.)
QUESTIONS YES NO
3. Do you feel any eye strains after playing a video game for
several hours?
4. Are there situations where you seem to have a difficulty in
seeing things clearly at a far away distance after playing
video games?
5. Are there situations where you seem to have a difficulty in
seeing things clearly within a short distance after playing
video games?

If you answered YES in question # 1:

3 3
hours hours
QUESTIONS
and and
below above
6. How long do you play a video game in one sitting?
Directions: Encircle the letter that best describe your answer.
7. How far are you from the screen whenever you are playing a video game?

A. Less than 20 inches

B. 20 INCHES

C. MORE THAN 20 INCHES

 Once More
a than
QUESTIONS week twice
a
week
8. How often do you play video games?

(Practice in Studying)

QUESTIONS YES NO
1. Do you like reading?
2. Do you like reading in dim places?
3. Do you prefer reading a book up close or near you face?
4. Do you prefer sitting in front of the class whenever you are
copying from the blackboard because you have difficulty in
reading the written lecture?
5. Are there situations where you seem to have difficulty in
seeing things clearly at a far away distance after studying or
reading books, notes, or other reading materials.
6. Are there situations where you seem to have difficulty in
seeing things clearly within a short distance after studying or
reading books, notes, or other reading materials.

3 3
hours hours
QUESTIONS
and and
below above
7. How long do you read or study your lessons in one sitting?
Directions: Encircle the letter that best describe your answer.
8. How far is the book or any reading material from you when you are reading?

A. 5-10 inches apart from the face

B. From the elbows to the knuckles of the hand

C. You can read even beyond your arm’s reach

 Once Twice Thrice
QUESTIONS in a in a in a
day day day
9. How often do you read or study?

(Diet)

QUESTIONS YES NO
1. Do you like eating vegetables?
2. If YES, do you frequently eat carrots?

Once More
a than
QUESTIONS week twice
in a
week
1. If you are eating the above mentioned vegetable, how often
do you eat it in a week?