Bloomington Eye Center – New – Patient Registration Forms

Name

First Last

Date of Birth

Sex

SS #

Address

Street Address Address Line 2 City State ZIP Code

Email

Home Phone

Cell Phone

Last Eye Exam

Occupation

Hobbies

How did you hear about us?

Interested in:

Glasses
Contacts
LASIK

Do you currently wear:

Glasses
Contacts
Both

Do you Currently have or have you ever had any of the following?

Check all that apply.

If other:

Do you have:

Diabetes
High Blood Pressure
Headaches

If you have High Blood Pressure, when were you diagnosed?

If you have Diabetes, when were you diagnosed?

Are you currently on any prescription or over the counter medications? Please List:

Do you currently have any Allergies known or perceived?

Do you have any problems with any of these systems?

Check all that apply

Do you use Tabacco?

If yes, how many per day?

Do you consume Alcohol?

If yes, how many per day?

Other substances?

Family Eye History

Cataracts
Cornea Disease
Retina Disease
Glaucoma
Lazy Eyes
Diabetes
Macular Degeneration
High Blood Pressure
Other Eye Disorder

Anyone in the patient's family (blood relative) had any of the following?

List any type of surgery

Surgery	Date of Sugery

Visual Field Screening

Would you be interested in automated testing of your peripheral vision? This test can detect underlying neurological changes, early glaucoma vision loss, as well as retinal disease. This test is not covered as a screener by any insurance company, nor is it required by Dr. Tyler. It is simply an additional test which you can choose to take to screen for some of the above conditions

Yes I would like the Field Screening ($25 not covered by insurance)
No I will forgo the screening at this time

Bloomington Eye Center New Patient Health History Form

Visual Field Screening