Diabetic Report

Diabetic Report
Professional VisionCare Location:

185 South State St, Westerville, OH 43081703 W Coschocton St, Johnstown, OH 430317100 Graphics Way, Suite 3200, Lewis Center, OH 43035
Patient Name*
Date of Birth*
Date of Exam*

MonthDayYear
Date
Retinal Exam*
IOP OS*
IOP OD*
Best Corrected Visual Acuity OD *
Best Corrected Visual Acuity OS*
Medical Diagnoses*

GlaucomaARMDCataractsHypertensive RetinopathyNo Diabetic RetinopathyMild Non-Proliferative Diabetic RetinopathyModerate Non-Proliferative Diabetic RetinopathySevere Non-Proliferative Diabetic RetinopathyMild Proliferative Diabetic RetinopathyModerate Proliferative Diabetic RetinopathySevere Proliferative Diabetic RetinopathyMild Diabetic Macular EdemaModerate Diabetic Macular EdemaSevere Diabetic Macular EdemaNAG-BPOAG-BOther
Further Treatment Recommended

OCT RNFLOCT MACPhotosDilationMonitor OnlyThresh 10-2Thresh 24-2Other
Follow Up Appointment

MonthDayYear
Date
Additional Measures

Amsler Grid given to monitor at home dailyRecommend follow up with PCPRecommend daily eye vitaminsEducated patient on blood sugar control and DFE
Optometrist Signature*

Clear
Optometrist*
Managing Physician*
Should be Empty: