EFTA02314187
EFTA_R1_01205761
Are you having any problems with your vision?
[ ] Yes [ ] No
LENSCRAFTERS
If yes: 1199 FIRST AVENUE
[ ) Far Away 1199 FIRST AVENUE AT 65TH STREET
[ Close Up I !n Between
NEW YORK, NY 10021
Phone: (212) 744-5149
What type of work do you do? Fax: (212) 744.5176 le•
O111-110
Do you use a computer? [ ] Yes [ I NO
Patient Name'
Sun: 49 .t 7 V I Date:
Reading: [ Extended Reading Sphere Sylincler Axis Prom Add
[ ] Very Close/Fine Detail Stele Vision
Do you have problems with bright lights or glare? I Proyessare
OD ill< ( j Moral
] Yes [ ]No I j Telocal
If yes, when do you notice this? ,. I 3 Distance
OS 1 —) .74 J. ;Lc
( ) Near
On-coming headlights [ ] Computer Screen
[ ] Glare from windshield [ ] Sunlight
Work/Primary
What sun protection do you currently wear?
Sphere Cylinder Axle A
titetngse Vetion
What hobbles/activities do you enjoy? [ I PlogfasSrve
OD
A--i ( I Bifocal
( j Trifocal
/
Do you engage In any activities that could cause OS Dry.: ( I Distance
[ 1 Near
eye injury?
Computer/ yawl( t _ .e n
Are you currently a contact lens wearer?
Sphere Cylinder AZ: Pram Add 'I Add 2
[ Yes What do you like [VI dislike [N] about your
contacts?
No vrs.on
[ vision ] Comfort I I Convenience OD 4- t4 vU Progressne
[ I Dryness [ 1 PRIO
[ ] No Have you ever worn contacts? [Y] [N] OS .4-11.1“ / n ct)0 Bifocal
Do glasses get in the way of any activities?
(golf, swimming, etc.) Safety/Speda ty:
Would you like to erWre-the latest advances n Sphere Cylinder Axis Priam Add
contact lenses? [ ) Single Vision
( 1 Progiessiye
I ] Yes OD
[ No 1 j Bifocal
1 j Trifocal
What do you like rirl dislike [N] about your current OS 1 j Delano)
oyewear? [ I Naar
[ [ Weight [ I Thickness [ ] Fit I I Style Match Prior: BC ( Yes No
[ [ Shape I ] Durability [ ] Size [ ] Color
Ma Copy - Patient Yellow Copy - Dispenser Pak
Copy - Foe
OD License #
1177 _3,
I Expires.
i O1
Di Remarks:
OC ()Yes (]No PD—/ mm
EX-067-LC 1L j
CP#3008024