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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.