Eye and Ear Infection Quiz
Answer the following questions to assess your risk for eye and ear infections. This quiz is for informational purposes only and does not replace professional medical advice.
Full Name
*
First Name
Last Name
Age
*
Which of the following symptoms are you currently experiencing? (Select all that apply)
*
Eye redness
Eye discharge
Itchy eyes
Ear pain
Ear discharge
Hearing loss
Fever
Other
How severe are your symptoms?
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
How long have you been experiencing these symptoms?
*
Less than 24 hours
1-3 days
4-7 days
More than a week
Do you have any of the following risk factors? (Select all that apply)
Recent cold or upper respiratory infection
History of allergies
Recent swimming
Contact lens use
None of the above
Have you experienced any of the following urgent symptoms? (Select all that apply)
*
Severe pain in eye or ear
Sudden vision or hearing loss
Swelling around the eye or ear
Severe headache
None of the above
Please rate your level of discomfort today.
*
1
2
3
4
5
Which side is affected?
*
Right side
Left side
Both sides
Do you have any other medical conditions we should know about? If yes, please specify.
Would you like to receive follow-up information or advice based on your responses?
Yes, by email
Yes, by phone
No, thank you
Email Address (if you would like follow-up)
example@example.com
Phone Number (if you would like follow-up)
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Quiz
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