Vision Dynamics Optometry

A Tradition of Superior Eyecare

Doctors Randy Yamada O.D. and Amy Lin O.D.

Danville, CA

925.838.3021

Vision Dynamics Optometry
Eye Health Services
Eye Conditions
Our Eyecare Staff

Contact Vision Dynamics
Lenses and Frames
News and Promotions
Order Contact Lenses Online
Orthokeratology Therapy
Submit a Patient History Form

Submit a Patient History Form

Save time by filling out a patient history form online before arriving for your examination!

There’s no need to print out your history form. Just fill out and submit the form below, and we’ll have your history on file when you arrive!

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First Name
MI
Last Name
Birthdate
Email
SSN
Address
City
State
Zip
Work Phone
Home Phone
Mobile Phone

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Today's Date
Date of Previous Exam
Were you dilated?
Yes No
When is your appointment?

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Referred by
Occupation
Employer
Emergency Contact Name
Emergency Contact Phone Number

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How's your general health?
Any health problems?
Gastrointestinal Ear / Nose / Throat Cardiovascular Respiratory High Blood Pressure Nervous Urinary Muscles / Bones Integumentary (skin) Eyes Endocrine (glands) Blood / Lymph Allergic / Immunologic Headaches Mental None of the Above
If yes, please explain.

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Do you have diabetes?
Yes No Not Sure
If yes, which type?
Date of diabetes diagnosis

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Any other health problems?
Are you currently on any medications?
Yes No Not Sure
If yes, which type of medications?

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Allergies to medication?
Yes No Not Sure
If yes, which type of medications?
Allergic reactions?

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Any surgeries or operations?
Yes No Not Sure
If yes, what type of surgery or operations? When?

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Name of family doctor
Last doctor visit
Last tetanus shot

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Family health problems
High Blood Pressure Diabetes Glaucoma Macular Degeneration Retinal Detachment Cataracts None of the above
If yes, please explain.

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Any eye conditions or problems?
Yes No Not Sure
If yes, please explain.

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Any eye injuries?
Yes No Not Sure
If yes, please explain.

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Any eye surgeries or operations?
Yes No Not Sure
If yes, what type? When?

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Any eye issues?
Glaucoma Cataracts Dry Eyes Macular Degeneration Retinal Detachment Blurred Vision None of the above
If yes, please explain.

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Do you wear:
Glasses Contact Lenses None of the above
If yes, which type?

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Any additional information, questions, or comments?
Human verification: What color is snow?

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Office Hours:	Open	Close
Monday, Tuesday	9:00 am	6:00 pm
Wednesday	9:00 am	5:00 pm
Thursday	9:00 am	6:00 pm
Friday	9:00 am	5:30 pm
Select Saturdays	9:00 am	2:00 pm
2011 OPEN Saturdays: 6/4, 6/18, 7/9, 8/13, 8/27
Sunday	Closed

Phone: 925.838.3021

Fax: 925.838.9068

417 Sycamore Valley Road West

Danville, California 94526

Click here for driving directions.

General Email: contact@vision-dynamics.com

Email Dr. Lin: drlin@vision-dynamics.com

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