EFTA00553155.pdf

EFTA00553155 Are you having any problems with your vision? [ ] Yes [ ] No LENSCRAFTERS IF-NS Vp.TERN.L. If yes: 1199 FIRST AVENUE 1199 FIRST AVENUE AT 65TH STREET [ ] Far Away [ ] Close Up What type of work do you do? [ ] ln Between NEW YORK, NY 10021 Phone il Patient Namei Fax: 1, 1 Date' t l 6 Do you use a computer? [ ] Yes [ ] No Sun: Reading: [ ] Extended Reading Sphere Cylinder Axis Prism Add [ ] Very Close/Fine Detail Single Viskin Do you have problems [ ] Yes with bright lights or glare? I ] No OD tn.( ,, I Hatininfos Bifocal I ) Trifocal If yes, when do you notice this? I [ Distance OS -9,7 k; .-° i 2-5- 010 - I I Naar [ ]On-coming headlights [ ) Computer Screen [ ) Glare from windshield I ] Sunlight Work/Primary. What sun protection do you currently wear? Sphere Cylinder Axis Prism Add 4 1-6ingee Vision / What hobbles/activities do you enjoy? OD irtiC I ] PrOgrOSSMI [, Bifocal I I Tnfocal Do you engage in any activities that could cause OS t'). K -°,26" °cc [I Distance eye injury? I I Near Are you currently a contact lens wearer? Compute r2, ..941A Sphere Cylinder Axis Prism Add 1 Add 2 [ ] Yes What do you like [Y) dislike IN) about your contacts? ^Ole vision [ j Vision I ] Comfort I ) Convenience OD P:mosso* 41.1 00 ✓ [ Dryness [ [ PRIO OS I 3Bilocee ] No Have you ever worn contacts? [Y] [NJ .44/5D —03-c 0 4 /0 Do glasses get in the way of any activities? (golf, swimming, etc.) Safety/Specia ty: Pmiryou like to explore the latest advances in Sphere Cylinder Axis Prism Add contact lenses? ( Sincm Vision [ Progressive [ ] Yes OD I Bifocal [ ] No I Trifocal What do you like [Y] dislike [N] about your current OS [ Pastor eyewear? I Near [ [ Weight [ ] Thickness [ ] Fit [ ] Style I I Shape [ ] Durability [ ] Size Mee Copy - Patient Yellow Copy - Dispenser PM Copy - Fle I ] Color -u Cen O D. Match Prior: Remarks: BC OC Yes ( Yes f I No [1No PD mm OD License # • i° 9 -Fxpires: /__L (1 EX-067-LC CPN3008024