Dr. Lucy Wun and Associates 10525 S. De Anza Blvd. #190, Cupertino, CA 95014 Tel: (408) 725-1900     Fax: (408) 725-1989    Email: staff@svoptometry.com
Last Name                       First Name                       MI        Gender     Birth Date       Age Male Female
Home Address                 City                                 State      ZIP     Email
Home Number                  Cell Number                    Work Number
Vision Insurance               Name of Insured              Birth Date          Relationship to Insured    Employer Name           Self Spouse Parent Dependant Other
Medical Insurance Name         (Select One)       Primary Member ID#          PPO HMO
Social Security # (Primary Member or Name of Insured)      Referred By           xxx-xx-
Signature (If under 18 years, parent or guardian signature is required.) X ________________________________________________________                (Not required when use on-line registration.)
Patient History
1. AGE OF PRESENT GLASSES  Years    LAST EYE EXAM  FROM DR.
2. HAS ANY MEMBER OF YOUR FAMILY EVER BEEN TO THIS OFFICE?    (full name)  age   Relationship Father Mother Brother Sister Others
3. DO YOU OR ANY OF YOUR FAMILY MEMBERS HAVE: No Yes Diabetes, if Yes, Who Self Father Mother Brother Sister Grandparents Others                  No Yes High Blood Pressure, if Yes, Who Self Father Mother Brother Sister Grandparents Others       No Yes High Cholesterol, if Yes, Who Self Father Mother Brother Sister Grandparents Others       No Yes Thyroid Problems, if Yes, Who Self Father Mother Brother Sister Grandparents Others       No Yes Cataracts, if Yes, Who Self Father Mother Brother Sister Grandparents Others                 No Yes Glaucoma, if Yes, Who Self Father Mother Brother Sister Grandparents Others No Yes Keratoconus, if Yes, Who Self Father Mother Brother Sister Grandparents Others             No Yes Smoker, if Yes, Who Self Father Mother Brother Sister Grandparents Others No Yes Retina Detachment, if Yes, Who Self Father Mother Brother Sister Grandparents Others   No Yes Macular Degeneration, if Yes, Who Self Father Mother Brother Sister Grandparents Others
4. ARE YOU TAKING ANY MEDICATION? No Yes Please list:
5. ARE YOU ALLERGIC TO ANY MEDICATION? No Yes Please list:
6. HAVE YOU EVER HAD AN EYE INFECTION, DISEASE, INJURY OR SURGERY? No Yes Please list:
7. DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS?    - Have you ever seen double? No Yes        - Do you get frequent headaches? No Yes        - Do bright lights bother you? No Yes        - Do you have trouble with night vision? No Yes
8. HAVE YOU EVER WORN CONTACT LENSES? No Yes
9. DO YOU PRESENTLY WEAR CONTACT LENSES? No Yes
10. HOW OLD ARE YOUR CONTACT LENSES?       R   L   Fitted By
11. TYPE OF CONTACT LENSES WORN (PLEASE CHECK ALL THAT APPLY): Hard Gas Permeable Soft - Disposable Soft - Conventional/Daily Soft - Extended Wear Tonic Bifocal
12. DO YOU WORK WITH A COMPUTER? No Yes
13. WHAT SPORTS AND HOBBIES DO YOU ENJOY?
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