rinehart family eye care eyeglasses: please bring all pairs of eyeglasses you currently use,...
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7801 Glenlivet West Road, Fogelsville, PA 18051 Phone: (610)-841-4944 | Fax: (610)-841-4948 www.rinehartfamilyeye.com
RINEHART FAMILY EYE CARE
As a new patient to our practice, we would like to offer a warm welcome and our thanks for choosing us to provide
your eye health and vision care. In order for us to establish your file, and provide the most beneficial use of your
time with us, the doctor has asked you to complete the following tasks and bring the results to your appointment.
The doctor needs this information in order to give you the best care possible.
□ Completed Welcome to the Office Form: This diagnostic information includes personal and family
information needed to establish your file, as well as your current eye health and vision status. Your
responses will guide our doctors and staff, and remind us to address any significant issues during your
□ Completed Medical and Eye Health History: Since many general health conditions may be associated
with visual symptoms and/or eye health problems, this important record (now required by state health
boards and virtually any medical and optical insurance plans) will allow us to care for you as a “whole
person” rather than just a pair of eyes. This form includes a complete list of prescription and non-
prescription medication, which may be brought in as a separate list for us to photocopy if you prefer.
□ Insurance cards or claim forms: For any optical and/or medical insurance you may be covered by.
(Even for “routine” visits, if a medical eye condition is discovered during your examination we can submit
a claim to your health insurance for the medical evaluation portion of your examination.)
□ Eyeglasses: Please bring ALL pairs of eyeglasses you currently use, including prescription or non-
prescription reading glasses, sunglasses, etc. We have instruments to compare the optical power of your
old lenses with your new exam findings, thus enabling us to determine and explain how your vision has
changed over time. We can also evaluate the condition and fit of your current eyewear.
□ Contact Lenses: It is best to wear your current contacts to your appointment if possible. Next best is to
bring them along in your case. If you wear planned replacement or disposable lenses, it is very helpful if
you bring along your cartons or lens packets that indicate the lens series, power, manufacture, etc.
□ Eye drops, ointments, etc: Please place any eye drops or ointments that you use in a small bag and bring
it along with you. Your doctor will review whether these or appropriate or if a better option is available.
□ Dilation Explained: The doctor may need to use drops to dilate your eyes in order to fully evaluate their
internal health. This has the effect of temporarily increasing sensitivity to light and causing “fuzzy” vision
at a near (reading) distance. Therefore, if you want new eyewear or feel you may need to select new
eyewear, please come 15 to 20 minutes before your appointment time in order to look at our frame
Completing the task list for the items that apply to you will assure you of receiving the most thorough and
professional care possible and in a very efficient manner. We look forward to your visit!
WELCOME TO OUR OFFICE WELCOME TO OUR OFFICE
Date of Birth Age
Sex M F
How do you prefer to be contacted?
(Indicate #1 and #2 Choice):
Home #___Work #___Cell #___Text___Email___
Employer (or School)
Occupation (or Grade)
Spouse (or Parent’s Name)
Spouse (or Parent’s Work)
What is the major purpose of this visit?
Any problems with your current contact lenses or
VERY IMPORTANT! NEW PATIENTS ONLY: Who may we thank for referring you to our office?
Name of friend or relative
If not referred, how did you choose our office?
Yellow Pages: Which directory? ______________
Web Page: Which Web Site? _________________
Subscriber Birth Date
Primary Medical Insurance
Subscriber Birth Date
Do you participate in a flex spending account?
How will you settle your account today?
Cash Check Credit Card
Do you……(check box if your answer is yes)
..work at a computer?
..think you might benefit from thinner, lighter lenses?
..have interest in a “test drive” of the latest contact lens
..spend time outdoors? How much? Hrs/week
..have prescription sunwear?
..prefer not to wear your glasses at times?
..have more than 1 pair of current Rx eyewear?
..have family members in need of eyecare?
Have you ever experienced, been diagnosed or treated
for any of the following?
Blurry Vision Burning
Cataracts Corneal Abrasions
Crossed eye/Eye turn Double Vision
Eye Infections Eye Injury
Flash of light Floaters/Spots
Itchiness Lazy Eye
Macular Degeneration Occasional dryness
Retinal Detachment Sunlight Sensitivity
Tearing Trouble seeing at night
Other eye disorders
Insurance Information Patient Information
The mission of Rinehart Family Eye Care is to contribute to a
lifetime of healthy vision, proving each patient with the highest
quality vision care and consequent quality of life. We will seek
continuing education to remain at the forefront of our
profession and will offer the latest eye care technology,
professional services, and products. The visual needs and
wellness of each patient will always be our first priority.
Everything we do shall communicate this.
The information in this confidential case history form is critical to the evaluation of your vision and health.
Name of Family Physician
CURRENT MEDICATIONS (Rx or Over the Counter)
(List name of medications including eye drops, vitamins, &
birth control pills)
Allergies to medications? Yes No
If so, what medications?
Do you: Use cigarettes/tobacco: Yes No
If yes, how often:____________________
Drink alcohol: Yes No
If yes, how often:____________________
Use other substances? Yes No
Previous history of blood transfusion: Yes No
Have you ever been diagnosed or treated for the
following health problems? Yes No
Are you currently pregnant?
High Blood Pressure
Sexually transmitted disease
Unusual weight losses/gains
Patient Medical History
Date of Last Eye Exam
Previous history of eye surgery? Yes No
Have you ever tried contact lenses? Yes No
Do you currently wear contact lenses? Yes No
Are you satisfied with the vision and comfort of your
contact lenses? Yes No
Would you prefer clear contact lenses or colored contact