Download AOA Diabetic Eye Examination Report

AOA Diabetic Eye Examination Report
(www.aoa.org)
From:
To:
Date examined:
(Write in or apply company stamp)
Patient Information:
DOB:
Name:
Diabetes mellitus:
Type 1
Type 2
Duration of Diabetes (in years):
Gestational
Current Diabetes Therapy:
Results of Last Finger-stick blood glucose reading (per patient):
< 6 months
HbAlC:
Prediabetes
Insulin
N/A
> 6 months
Oral Hypoglycemic
Unknown
None
Diet Contol
Patient reports under control
Yes
No
Current Medications (ocular and systemic):
Exam Findings:
Visual Acuity (best corrected)
Intraocular Pressure OD:
Additional Ocular Findings:
OD:
OS:
within normal limits
> normal
OS:
within normal limits
> normal
Dilated Fundus Exam Performed
Diagnosis:
OD
No Diabetic Retinopathy
Non-Proliferative Diabetic Retinopathy
OD
Mild
OD
Moderate
OD
Severe
OD
Proliferative Diabetic Retinopathy
OD
Clinically Significant Macular Edema
Plan:
Monitor Only
-orAdditional Testing/Treatment Recommended:
OS
OS
OS
OS
OS
OS
Additional Comments:
Management:
Follow-up:
months
For:
Referral To:
Home central vision test (Amsler) given
Patient ed./discussion
Info. Pamphlet given
Other
Doctor's Signature
©This form was developed by the Ohio Optometric Association and The Ohio State University College of Optometry
through support from the NIH Healthy Vision 2010 Awards Program and an AOA Healthy Eyes Healthy People Grant.