Please ensure that this information is reported to the diabetes tracking agency. Referred for Diabetes Care. Blood Cholesterol. Recommend Tighter Control. A1C …
Healthy Eyes/Healthy People Diabetes Eye Exam Report
Your patient with diabetes was seen for their dilated fundus exam The results are as follows Please ensure that this information is reported to the diabetes tracking agency PATIENT NAME:___________________________________EXAM DATE:_________ DOB: __________________________________________________________________ TO primary care: ________________________________________________________ FROM eye care:_________________________________________________________
Diabetes History
Type 1 Gestational Impaired Glucose Tolerance Duration in years:________ Type 2 Current Diabetes Therapy Insulin Oral Hypoglycemics Diet Control Patient Reports: Good Control Fair Control Poor Control A1C_________
EXAM FINDINGS:
Presenting Symptoms:_____________________________________________________________________________ ______________________________________________________________________________ GENERAL Stable Changed Unk Cataract Rubeosis Arteriolar Sclerosis Hypertensive Retinopathy Vein Occlusion Artery Occlusion Glaucoma FUNDUS Stable Changed Unk No diabetic retinopathy Mild Nonproliverative Moderate Nonproliferative Severe Nonproliferative
Proliferative Diabetic Macular Edema Previous Laser Therapy ADDITIONAL COMMENTS
Treatment: Additional Testing Recommended: Continue Current Diabetes Care FBS Referred for Diabetes Care Blood Cholesterol Recommend Tighter Control A1C Referred to Retinal Specialist Lipid Profile Management: RTC Return to Clinic:___________Months Comments to the Patient
For additional forms, contact the Wyoming Diabetes Prevention and Control Program @ 307 777-3579
White- Referral Doctor Yellow- Patient Pink- File
print date April 2004
