Diabetic Eye Exam Form
What a diabetic eye exam form asks, with sample questions on diabetes history, blood sugar results, and eye history.
A diabetic eye exam form records diabetes type, recent blood sugar results, medicines, eye history, and other health conditions before a dilated eye exam. The questions on this page are built from the American Diabetes Association's eye exam visit form and retina practices' history forms.
Diabetic eye exam form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a diabetic eye exam form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample diabetic eye exam form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- What type of diabetes do you have?Diabetes history
- When were you diagnosed with diabetes?Diabetes history
- What was your last A1C result?Blood sugar
- Do you use a continuous glucose monitor?Blood sugar
- Which diabetes medicines do you take now?Medicines
- Are you allergic to any medicines?Medicines
- When was your last eye exam?Eye history
- Have you had laser treatment or eye surgery?Eye history
- Do you have high blood pressure?Other health
- Are you or could you be pregnant?Other health
- Who is your primary care provider?Care team
- Who should receive a copy of the results?Care team
These are examples to read, not a form to fill in.
Diabetic eye exam form: FAQ
What does a diabetic eye exam form ask?
The sample questions here are based on the American Diabetes Association's Diabetes Eye Exam Visit Summary and retina practices' new patient forms. This page groups them into six areas: diabetes history, blood sugar, medicines, eye history, other health, and care team.
Who fills in a diabetic eye exam form?
The patient answers the history questions before the exam. The American Diabetes Association visit summary is a separate form that the eye clinician completes.
Does it ask for the last A1C result?
The American Diabetes Association form has fields for the last reported A1C, continuous glucose monitor use, and time in range. AI Doctor records the number the patient gives and does not comment on it.
Why does it ask for the primary care provider?
One health plan's eye exam report for diabetes is returned by the eye care professional to the patient's primary care provider. The American Diabetes Association form is also addressed to another clinician.
Is there a diabetic eye exam form template?
The American Diabetes Association publishes a Diabetes Eye Exam Visit Summary that the eye clinician completes. The sample questions on this page show the patient's side.
What happens after the form is completed?
The eye care team reviews the answers before the dilated exam. Findings and follow-up are decided by the clinician, not by AI Doctor.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
