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Clinical Care and Practice Advancement
Clinical Care and Practice Advancement

AOA Diabetes Eye Report form



AOA Diabetes Eye Examination Report Form

Improve Communication with Health Providers and your Patients

The AOA Diabetes Eye Care Project Team in cooperation with the Ohio Optometric Association is pleased to offer a new AOA Diabetes Eye Examination Report form. This form was developed and field tested by Kelly Nichols, OD, MPH, PhD and Sylvia Jones, OD, MS of Ohio State University. Funding for the development and testing the form was received from two awards from the  National Eye Institute’s Healthy Vision 2010 Community Awards Program and a grant from the American Optometric Association’s Healthy Eyes Healthy People™ Program.

This new form was developed to improve communications about important ocular and systemic findings between the optometrist and a doctor of the patient’s choice following the eye examination. In addition, the form offers an opportunity to educate the patient about the importance of annual dilated eye examinations. The forms and a survey were sent to volunteer Ohio Optometric Association (OOA) member optometrists and physicians. Their responses were used to revise the form.

The copyrighted report form is in Adobe Reader and can be filled in online and printed to give a copy to the patient and send one to the patient’s doctor of choice. You can also print the form blank and write in your responses. You must have the patient’s permission to send the form to another doctor. You can not resave the information as a new PDF. The only way you will be able to do this is by using the full version of Adobe Acrobat. There are free utilities on the web such as PrimoPDF which allow for printing back to a PDF. Using a product such as this would be a possible solution to keeping the document in electronic form. The form with information filled in can then be saved as a PDF with the data that can not be altered but can be saved electronically.

In October, 2007, the AOA Order Department will be printing a triplicate version of this report form (one copy each for the patient, physician of choice, and the chart). The patient’s copy will have educational information about diabetes and the eye printed on the back side.

By using this form, you are agreeing not to alter the form’s appearance. We welcome any comments you may have about the new form, and these comments may result in future revisions. Send them to Uzma Zumbrink, MPH, at UAZumbrink@aoa.org.