Materials

Procedures

The Questionnaire

Questionnaire (Eye problems)                        By Sarah Kam

         (High School Division)

 Please circle one of the following answers.

2. Which ethnic group do you belong to?
    Asian     Caucasian     African     Hispanic     Other (please     
    specify): ___________

3. Do you have any eye problem(s)? (If No, go to Qs 9)  
    Yes     No

4. What kinds of eye problem(s) do you have?          
    Short-sightedness     Long-sightedness

5. Any other eye problem(s) do you have?            
    Strabismus     Astigmatism     Other     No

6. Do you wear glasses or contact lens? (If No, go to Qs 9):             
    Yes     No

7. If yes, how long have you been wearing them?
    1yr     2yrs     3yrs     4yrs     5yrs     6yrs     7yrs     8yrs     9yrs     
    Over 10yrs

8. Have you ever considered getting a Laser Surgery?      
    Yes     No

9. Do your parents wear glasses or contact lens?  
    Yes     No

10. How many hours do you spend on watching TV per day?
    1hr     2hrs     3hrs     4hrs     5hrs     6hrs     7hrs     8hrs     9hrs     
    Over 10hrs

11. How many hours do you spend on the computer per day?     
      (Working/playing games)
      1hr     2hrs     3hrs     4hrs     5hrs     6hrs     7hrs     8hrs     9hrs     
      Over 10hrs

12. How many hours do you spend on reading books per day?
      1hr     2hrs     3hrs     4hrs     5hrs     6hrs     7hrs     8hrs     9hrs     
      Over 10hrs 

13. Do you take Vitamin A?           
      Yes     No

14. If yes, how often?   _______________________

Congratulations! You have completed this questionnaire!
Thank you for your time!

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Last updated: April 28, 2007.