Acanthamoeba Infection Assessment
Please complete this form to help assess your risk and symptoms related to possible Acanthamoeba infection.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you experienced any of the following symptoms? (Select all that apply)
*
Eye pain
Redness of the eye
Blurred vision
Sensitivity to light (photophobia)
Excessive tearing
Feeling of something in the eye (foreign body sensation)
None of the above
Other
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate the severity of your symptoms?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Do you wear contact lenses?
*
Yes
No
If you wear contact lenses, how often do you clean or replace them?
Please Select
Daily
Every few days
Weekly
Rarely/Never
Not applicable
Have you recently been exposed to any of the following? (Select all that apply)
*
Swimming in lakes, rivers, or pools
Use of tap water for rinsing contact lenses
Eye trauma or injury
Recent eye surgery
None of the above
Other
Do you have any of the following medical conditions? (Select all that apply)
Immunosuppression (e.g., due to medication or illness)
Diabetes
None of the above
Other
Please provide any additional details about your symptoms, exposures, or medical history.
Submit Assessment
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