Surfrider Foundation- Ocean Illness Form

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SURFRIDER FOUNDATION OCEAN ILLNESS FORM

If you have been sick lately and think that it may be caused by ocean water contact, please tell us about it. If you have questions you want us to answer, send us a separate email.

Please complete the following form to submit to Surfrider.org

Date swimming/surfing:	, (if you think you've been sick more than once from the water, please select the last day you were in the water before your most recent illness. Choose "- -" if you can't remember the exact day, but select a month and year.)
Time of day:
Name of beach:
Beach is in (or closest to) what city or town?:
Beach is in what State/Province?
Country:
Your Name:	(optional)
Age:
Email:	(optional)

Describe your illness and physical symptoms
How long after you were in the ocean did your illness symptoms start?
How long did your illness last?
Did you see a doctor?	Yes No
If you were treated by a doctor, what was the diagnosis and treatment?
How many times have you been sick from the ocean at the beach you listed above?	1 time 2 times 3 times More than 3 times (If you got sick after water contact at another beach, please fill out this entire form again)
Did anyone else become ill that had been in the water at the same location? Describe
Add any other comments you have:

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