Fundoscopic Exam Documentation Form
Complete this form to record findings and clinical impressions from a fundoscopic eye examination.
Patient Initials or ID
*
Exam Date
*
-
Month
-
Day
Year
Date
Patient Age
*
Examined Eye(s)
*
Right Eye (OD)
Left Eye (OS)
Optic Disc Findings
*
Please Select
Normal
Pallor
Cupping
Blurred Margins
Other
Retinal Vessel Findings
*
Please Select
Normal
Attenuation
AV Nicking
Tortuosity
Hemorrhages
Other
Macula Findings
*
Please Select
Normal
Edema
Drusen
Hemorrhage
Other
Notable Abnormalities or Additional Findings
Clinical Assessment/Impression
*
Recommended Next Steps / Plan
*
Submit Documentation
Should be Empty: