AOA Diabetes Eye Report form

Improve Communication with Health Providers and your Patients

Diabetes Eye Examination ReportThis 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 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.  A word version of this form is available upon request to aid in incorporating the information into your office's EHR.

The AOA Order Department offers this document in a printed triplicate version (one copy each for the patient, physician of choice, and the chart).

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