Examination form

Date____________ Name: ___________________________, Project No: __________, DOB:_____ Male/female: _____
Exam	RE	LE
VA	SC/CC/PH	SC/CC/PH
IOP by tonopen
FDT visual fields
photography
Ophthalmologists examination
Cornea
Lens status	Cataract/IOL/aphakia	Cataract/IOL/aphakia
If Cataract - type and grade
Vertical CDR
Notch	Yes/no	Yes/no
PPA	Yes/no	Yes/no
Disc hemorrhage	Yes/no	Yes/no
Visual fields defect	Yes/no	Yes/no
Glaucoma	Category 0 Category 1 Category 2 Category 3 Glaucoma suspect	Category 0 Category 1 Category 2 Category 3 Glaucoma suspect
Diabetic retinopathy	None CSME Mild NPDR Moderate NPDR Severe NPDR PDR Retinal Laser done	None CSME Mild NPDR Moderate NPDR Severe NPDR PDR Retinal Laser done
AMD	Yes/no	Yes/no
Other fundus pathology (describe)

CSME: Clinically significant macular edema, NPDR: Nonproliferative diabetic retinopathy, PDR: Proliferative diabetic retinopathy, ETDRS: Early treatment diabetic retinopathy study, AREDS: Age-related eye disease study