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Bloomington Eye Center – Newadmin2017-07-06T01:14:26+00:00

Bloomington Eye Center New Patient Health History Form

  • MM slash DD slash YYYY
  • Check all that apply.
  • Check all that apply
  • If yes, how many per day?
  • If yes, how many per day?
    Anyone in the patient's family (blood relative) had any of the following?
  • SurgeryDate 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
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