Are you having any problems with your vision? [ ] Yes If yes: [ ) Far Away [ ] No [ Close Up I !n Between What type of work do you do? Do you use a computer? [ ] Yes Reading: [ Extended Reading [ ] Very Close/Fine Detail Do you have problems with bright lights or glare? ] Yes [ ]No If yes, when do you notice this? On-coming headlights [ ] Computer Screen [ ] Glare from windshield [ ] 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 [VI dislike [N] about your contacts? [ vision ] Comfort I I Convenience [ I Dryness [ ] No Have you ever worn contacts? [Y] [N] Do glasses get in the way of any activities? (golf, swimming, etc.) Would you like to erWre-the latest advances n contact lenses? I ] Yes [ No What do you like rirl dislike [N] about your current oyewear? [ [ Weight [ I Thickness [ ] Fit I I Style [ [ Shape I ] Durability [ ] Size [ ] Color Ma Copy - Patient Yellow Copy - Dispenser Pak Copy - Foe EX-067-LC Patient Name' [ I NO Sun: OD OS LENSCRAFTERS 1199 FIRST AVENUE 1199 FIRST AVENUE AT 65TH STREET NEW YORK, NY 10021 Phone: (212) 744-5149 Fax: (212) 744.5176 7 V le• 49 .t I Date: O111-110 Sphere ill< Sylincler Axis Prom Add Stele Vision I Proyessare ( j Moral I j Telocal I 3 Distance ( ) Near 1 —) .74 J. ;Lc , . Work/Primary OD OS Sphere Cylinder Axle A--i Dry.: A Computer/ yawl( t _ .en Sphere Cylinder AZ: Pram Add 'I titetngse Vetion [ I PlogfasSrve / ( I Bifocal ( j Trifocal ( I Distance [ 1 Near Add 2 No vrs.on OD 4-t4 vU Progressne [ 1 PRIO OS .4-11.1“ / n ct) 0 Bifocal Safety/Speda ty: OD OS Sphere Cylinder Axis Priam Add [ ) Single Vision ( 1 Progiessiye 1 j Bifocal 1 j Trifocal 1 j Delano) [ I Naar OD License # 117 1L 7 _3, i O1Di I Expires. j Match Prior: