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Pink Eye Questionnaire

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I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.

​​​​​​​I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.

I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.

By selecting  below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
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What is your height?
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What is your weight in pounds
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To ensure your provider can safely evaluate your symptoms, we’ll ask a few questions about your health history, medications, and allergies.
Please identify all your current medical conditions
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Please list all your current medications including dosages.
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Please list all of your known allergies.
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Current Symptoms

What symptoms are you currently experiencing?
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Tell us more about your other symptoms
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Current Symptoms

Are you experiencing any of the following severe or urgent symptoms? (Select all that apply)
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Current Symptoms

When did your symptoms begin?
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Current Symptoms

Which treatments have you tried?
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What other treatments have you tried?
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Current Symptoms

Do you have any medication allergies (including eye drops or ointments) to any of the following? (Select all that apply)
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What other information or questions do you have for the doctor?
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Indication for Use:
You are requesting evaluation and treatment for pinkeye (conjunctivitis), which may be caused by a viral, bacterial, or allergic process.Treatment will be based on your symptoms and medical history. Common medications that may be prescribed include:



Topical Antibiotics (for bacterial conjunctivitis):


  • Erythromycin ophthalmic ointment
  • Trimethoprim–polymyxin B (Polytrim) drops
  • Ciprofloxacin (Ciloxan) drops or ointment
  • Ofloxacin (Ocuflox) drops
  • Moxifloxacin (Vigamox) drops
 
    Allergic Conjunctivitis:
     
    • Azelastine (antihistamine) drop
     
      For Comfort and Supportive Care:
       
      • Lubricating or artificial tear drop
       
        These treatments work by reducing infection, inflammation, and irritation of the conjunctiva (the thin layer covering the white part of your eye and inner eyelids).

        Potential Benefits:
         
        • Resolution or improvement of redness, irritation, and discharge
        • Relief from itching, burning, or discomfort
        • Prevention of spreading infection to others
        • Protection from complications such as corneal involvement or vision changes
        • Improved comfort and faster recovery
         
          Potential Side Effects:

          While these medications are generally safe and well-tolerated, side effects can occur. Common and serious side effects include, but are not limited to:

          Common Side Effects:


          • Temporary stinging or burning with application
          • Blurry vision immediately after use
          • Mild eye irritation or redness
          • Watery eyes


          Serious Side Effects (rare):

          • Allergic reactions such as itching, swelling, or rash around the eyes
          • Eye pain, worsening redness, or vision changes
          • Signs of corneal ulcer or worsening infection
          • If any of these occur, stop using the medication and seek medical care promptly.

           
            Risks and Considerations:
            • Contact Lenses: Do not wear contact lenses during active infection. Contacts can trap bacteria or viruses and delay healing. You should wait at least 24–48 hours after symptoms fully resolve before resuming use and should replace or disinfect all lenses, cases, and open solutions.
            • Spread Prevention: Wash hands frequently and avoid touching or rubbing your eyes. Do not share towels, makeup, or pillowcases.
            • Allergic Conjunctivitis: Symptoms are typically itchy, watery, and seasonal. Antihistamine drops (such as azelastine) can reduce inflammation but will not treat infections.
            • Bacterial Conjunctivitis: Typically causes thick, yellow-green discharge and matting of the eyelids. Topical antibiotics are effective and usually result in improvement within 2–3 days.
            • Viral Conjunctivitis: Often associated with cold symptoms and watery discharge. Antibiotics are not effective, but lubricating drops may help with comfort.
            • Follow-up: If symptoms do not improve within 3–5 days, or if you experience pain, light sensitivity, or vision changes, you should seek in-person evaluation by an eye specialist.

             
              Monitoring and Follow-up:
              • You may be asked to provide updates through follow-up questionnaires to assess your response to treatment. If your condition does not improve as expected or worsens, you will need to be evaluated in person by an optometrist or ophthalmologist. For contact lens wearers, your provider may request confirmation that your lenses, case, and solutions have been replaced or disinfected before resuming use.

                I acknowledge that I have reviewed and understand the potential benefits, risks, and side effects of medications that may be prescribed for the treatment of pinkeye (conjunctivitis). I understand the importance of discontinuing contact lens use until my infection has resolved, maintaining good hygiene, and seeking further care if my symptoms worsen or do not improve.
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                Please attest to the following confirming that all information you have provided to us is true and complete.

                I verify that I am the patient and that I have answered the questions asked in this intake form.  I confirm that I have reviewed and understood all the questions asked of me.  I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor.  I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
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                Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.

                What you were seeking help for:

                • Pink Eye

                Why this happens

                Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.
                Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

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