"Diabetes Eye Exam Report Form"

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Diabetes Eye Exam Report
TO: _________________________________________ Clinic/Office: _____________________
Address:
_____________________
Phone: ________________________ Fax: ____________
Patient Name: ____________________________________
DOB: ________________
Visual Acuity: _________ R _________ L
Intraocular Pressure _______ R _______ L
Retinal Examination Findings:
_______
No retinopathy or past retinopathy and should be examined in one year.
_______
Needs no laser now, but should return in ________ months because of risk of developing diabetic
macular edema (DME) or high risk of proliferative diabetic retinopathy (PDR)
_______
Diabetic macular edema requiring focal laser photocoagulation
_______
High risk proliferative diabetic retinopathy or iris neovascularization requiring panretinal
photocoagulation
_______
Tractional retinal detachment or vitreous hemorrhage requiring vitrectomy
Other Ocular Conditions:
_______
Not applicable
Cataracts:
_______
Does interfere with activities of daily living
_______
Does not interfere with activities of daily living
_______
Not applicable
Glaucoma:
_______
Controlled
_______
Sub-optimally controlled
_______
Not applicable
Plan of Treatment:
Follow-up ________________ weeks/months
_______
Refer to Retina Specialist
OR:
(check appropriate treatment plan)
(Circle right eye “R” or left eye “L” or both)
_______
Fluorescein angiogram
R
L
B
_______
Panretinal laser photocoagulation
R
L
B
_______
Focal laser photocoagulation
R
L
B
_______
Vitrectomy
R
L
B
_______
Cataract Surgery
R
L
B
_______
Other:
Eye Care Provider (M.D. or O.D.)
Print Name: __________________________ Signature: ____________________ Date: _______
_________________________________________ ___________________
_______________
Clinic/Office Name
Phone
Fax
I give permission to release this information to my Physician ______________________________
Patient Signature
33
Diabetes Eye Exam Report
TO: _________________________________________ Clinic/Office: _____________________
Address:
_____________________
Phone: ________________________ Fax: ____________
Patient Name: ____________________________________
DOB: ________________
Visual Acuity: _________ R _________ L
Intraocular Pressure _______ R _______ L
Retinal Examination Findings:
_______
No retinopathy or past retinopathy and should be examined in one year.
_______
Needs no laser now, but should return in ________ months because of risk of developing diabetic
macular edema (DME) or high risk of proliferative diabetic retinopathy (PDR)
_______
Diabetic macular edema requiring focal laser photocoagulation
_______
High risk proliferative diabetic retinopathy or iris neovascularization requiring panretinal
photocoagulation
_______
Tractional retinal detachment or vitreous hemorrhage requiring vitrectomy
Other Ocular Conditions:
_______
Not applicable
Cataracts:
_______
Does interfere with activities of daily living
_______
Does not interfere with activities of daily living
_______
Not applicable
Glaucoma:
_______
Controlled
_______
Sub-optimally controlled
_______
Not applicable
Plan of Treatment:
Follow-up ________________ weeks/months
_______
Refer to Retina Specialist
OR:
(check appropriate treatment plan)
(Circle right eye “R” or left eye “L” or both)
_______
Fluorescein angiogram
R
L
B
_______
Panretinal laser photocoagulation
R
L
B
_______
Focal laser photocoagulation
R
L
B
_______
Vitrectomy
R
L
B
_______
Cataract Surgery
R
L
B
_______
Other:
Eye Care Provider (M.D. or O.D.)
Print Name: __________________________ Signature: ____________________ Date: _______
_________________________________________ ___________________
_______________
Clinic/Office Name
Phone
Fax
I give permission to release this information to my Physician ______________________________
Patient Signature
33