Please complete this form for any complaints of eye discharge, redness or irritation. If you have light sensitivity or have any visual loss you should seek immediate attention by calling us or going to the ER

Name * Date of Birth * Choose your medical practice What type of insurance do you have? * Date symptoms started Which Eyes are infected Do bright lights make your eyes hurt? Does the black part of your eye get bigger and smaller if you shine a light in it? Do you have any blurred or double vision? Is your vision impaired in any other way? Is there discharge from your eye? Do you have any redness or swelling around your eyes ? Do you where contacts? If yes have you taken out your contacts? If you when was last time you changed contacts Are the whites of your eyes red? Have you been exposed to anyone with pink eye? Have you put any medication in eyes? Are any of your eye lids swollen? Do you work in food industry or in school setting? Do you have much direct contact with general public at your job Any other information you would like to tell us? Best Method of Contact Best contact number or email