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:	- - Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec. - - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , - - 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 (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?	outside the USA AK AL AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY not listed here
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:
For security reasons, please write ONE of the above 2 words: