Diabetic Retinopathy Eye Exam Checklist Form
Please complete the Diabetic Retinopathy Eye Exam Checklist Form to document key findings and details for the exam.
Patient Initials
*
Date of Exam
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Examiner's Name
*
First Name
Last Name
Visual Acuity (Best Corrected)
*
Retinal Findings
*
No Abnormalities
Microaneurysms
Hemorrhages
Hard Exudates
Cotton Wool Spots
Neovascularization
Macular Edema
Other
Diabetic Retinopathy Severity
*
None
Mild Non-Proliferative
Moderate Non-Proliferative
Severe Non-Proliferative
Proliferative
Is Follow-up Recommended?
*
Yes
No
Recommended Follow-up Interval
Please Select
3 months
6 months
12 months
Other
Additional Comments
Submit Checklist
Should be Empty: