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Annual Health Appraisal
NameLastDOBFirstSportCell Phone
Current Eligibility Airshaft___ Weight ___ Pulse ___ BP___/___
SeatedVision R 20/___L 20/___w/Correction Y N Glasses Lenses If elevated f/u:
Date___
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Individuals who have purchased glasses, sunglasses, or contact lenses from Eyeconic are required to file glasses sunglasses and contactseyeconic.
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