Are you having any problems with your vision? [ ] Yes [ ] No If yes: [ ] Far Away [ ] Close Up [ ] ln Between What type of work do you do? Do you use a computer? [ ] Yes [ ] No Reading: [ ] Extended Reading [ ] Very Close/Fine Detail Do you have problems with bright lights or glare? [ ] Yes I ] No If yes, when do you notice this? [ ]On-coming headlights [ ) Computer Screen [ ) Glare from windshield I ] Sunlight What sun protection do you currently wear? What hobbles/activities do you enjoy? Do you engage in any activities that could cause eye injury? Are you currently a contact lens wearer? [ ] Yes What do you like [Y) dislike IN) about your [ contacts? j Vision I ] Comfort I ) Convenience [ Dryness ] No Have you ever worn contacts? [Y] [NJ Do glasses get in the way of any activities? (golf, swimming, etc.) Pmiryou like to explore the latest advances in contact lenses? [ ] Yes [ ] No What do you like [Y] dislike [N] about your current [ eyewear? [ Weight [ ] Thickness [ ] Fit [ ] Style I I Shape [ ] Durability [ ] Size I ] Color Mee Copy - Patient Yellow Copy - Dispenser PM Copy - Fle EX-067-LC LENSCRAFTERS 1199 FIRST AVENUE 1199 FIRST AVENUE AT 65TH STREET NEW YORK, NY 10021 Phone Fax: Patient Namei OS OD Sun: ,1 1 Date' t IF-NS Vp.TERN.L. i l l 6 Sphere Cylinder Axis Prism Add Single Viskin I Hatininfos ,, Bifocal I ) Trifocal I [ Distance I I Naar tn.( -9,7k; .-° i 2-5- 010- OS OD Work/Primary. Sphere Cylinder Axis Prism Add 41-6ingee Vision I ] PrOgrOSSMI [ , Bifocal I I Tnfocal [ I Distance I I Near / ri tiC t'). K -°, 26" ° cc OS OD Compute r2, ..941A Sphere Cylinder Axis Prism Add 1 Add 2 ^Ole vision P:mosso* [ [ PRIO I 3Bilocee ✓ 41.1 00 .44/5D —03-c 0 4 /0 Safety/Specia ty: OS OD Sphere Cylinder Axis Prism Add I [ I I [ ( Sincm Vision Near Pastor Trifocal Bifocal Progressive u - Cen OD License # • i° 9 Fxpires: - O D. Match Prior: BC Yes f I No OC ( Yes [1 No PD mm Remarks: /__L (1 CPN3008024 EFTA00553155