Contact Lens-Related Eye Ulcer Assessment
Please complete this form to assist in the evaluation and management of eye ulcers associated with contact lens use.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Information (Email)
*
example@example.com
Contact Information (Phone Number)
Please enter a valid phone number.
Format: (000) 000-0000.
Do you currently wear contact lenses?
*
Yes
No
Type of contact lenses used
Please Select
Soft daily wear
Soft extended wear
Rigid gas permeable
Other
How long have you been experiencing symptoms?
*
Please Select
Less than 24 hours
1-3 days
4-7 days
More than 1 week
Symptoms experienced (select all that apply)
*
Eye pain
Redness
Blurred vision
Discharge
Photophobia (light sensitivity)
Other
Have you had any recent eye trauma or injury?
*
Yes
No
History of previous eye infections?
Yes
No
Clinical Assessment: Please rate the following findings
*
Rows
Absent
Mild
Moderate
Severe
Corneal ulcer size
1
2
3
4
Corneal infiltrate
5
6
7
8
Anterior chamber reaction
9
10
11
12
Hypopyon
13
14
15
16
Eyelid swelling
17
18
19
20
Visual Acuity (best corrected, affected eye)
Please Select
20/20
20/40
20/80
20/200
Worse than 20/200
Upload a photo of the affected eye (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional notes or relevant medical history
Signature (Patient or Guardian)
*
Submit Assessment
Submit Assessment
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