SO Red Eye Form

Red Eye Form
Date

DayMonthYear
Date
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Which eye is affected?*

RightLeftBoth
If both eyes affected, which was affected first?

RightLeft
How long has the redness been present?
Describe in time (hours, days) since you first noticed the redness.
Are you experiencing any light sensitivity?*

YesNo
Is your vision blurry?*

YesNo
Is there discharge from the eye?*

YesNo
If yes, please indicate quality of discharge.

WateryMucousPurulent
Please indicate colour of discharge if applicable:
Any recent illness (i.e. cold, fever, flu)?*

YesNo
Are your eyes experiencing any itchiness?*

YesNo
Are your eyes experiencing any pain?*

YesNo
Do you wear contact lenses?*

YesNo
If yes, when was the last time you wore contact lenses? blanks
Please attach images of the affected eye(s).

Cancelof
Should be Empty: