Eye Pain After Contact Lens Removal Report Form
Please complete this form to report any eye pain experienced after removing your contact lenses. Your responses will help us understand and address your symptoms.
Full Name
*
First Name
Last Name
Date of Report
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Contact Lens Worn
*
Please Select
Soft (daily wear)
Soft (extended wear)
Rigid gas permeable (RGP)
Hybrid
Scleral
Other
How many hours did you wear your contact lens before removal?
*
When did you first notice the eye pain?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
How would you rate the severity of your eye pain?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Which symptoms did you experience along with the pain? (Select all that apply)
*
Redness
Tearing/watery eyes
Blurred vision
Light sensitivity
Discharge
Swelling
No additional symptoms
Other
Please describe the location and nature of the pain (e.g., sharp, dull, burning):
*
Have you experienced similar eye pain before?
*
Please Select
No
Yes, once
Yes, multiple times
Submit Report
Should be Empty: