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Bloomington Eye Center – New
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2017-07-06T01:14:26+00:00
Bloomington Eye Center New Patient Health History Form
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Sex
Male
Female
Other
SS #
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
Eye Surgeries
Eye Injuries
Eye Infections
Amblyopia
Cataracts
Dry Eyes
Light Sensitivity
Pain
Glaucoma
Lazy Eye
Macular Degeneration
Eyes turn in/out
Reading Problems
LASIK
Other
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
Allergic / Immunologic
Arthritis
Blood / Lymph
Cardiovascular Heart Disease
Ear / Nose / Throat
Endocrine Glands
Gastrointestinal
Integument
Skin
Kidney Problems
Musculature
Nervous
Psychiatric
Respiratory
Skeletal Bones
Thyroid Problems
Other
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
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