Diabetic retinopathy-screening training program for nurses St John Eye Hospital - UNRWA

1. DIABETIC RETINOPATHY
SCREENING FORM
Dr. Riyad Banayot
St. John of Jerusalem Eye Hospital
Diabetic Retinopathy Screening

2. DR screening certificate.pub

3. Patient information
Name:………………… ID No:…………………………..
Birth date: :…./…../ Age:……..yrs Sex: M F
Contact Tel:…………………Mobile:……………………
Residence:……………… Occupation:…………………..
Call date: / / Appointment date: / /
Pt. attended Y N
Reasons for not attending:………………………………
New appointment date: / /

4. DM & Risk Factors
Diabetes Mellitus: Type: o 1 o 2 o Gestational
Duration:……yrs Controlled: o Y o N HbA1c:……%
Medication: o Tab o Insulin o Combination
HTN: o Controlled o Not controlled
Lipid Profile: o Normal o Abnormal o Rx
Renal Profile: o Normal o Abnormal o Rx o Dialysis
Fundus status & treatment
o Laser Rx in past o Laser Rx currently
o o IV injections in past o IV injections currently
o Vitrectomy in past o No active disease under FU

5. Examination & Grading
VA Unaided (Distance) ……/……. VA Corrected (Distance) ……/…….
o Pin hole o Spectacles o CL
LENS o Clear o Cataract o IOL
Fundus Photos o Screener Initials:……...
GRADING: ACTION (date)
o R0 No DR Annual screening
o R1 Mild NPDR Annual screening
o R2 Moderate NPDR Refer
o R2 Severe NPDR Urgent refer
o R3 PDR Urgent refer
o R3 Pre-retinal fibrosis Urgent refer
± tractional RD
o M0 No Maculopathy Annual screening
o M1 Diabetic Maculopathy Refer
o OL Other lesion Refer to assess
o UG Ungradable Refer to assess
o Patient informed date o GP informed date Grader Initials:……...

6. Consultation Grading & outcome
Consultation Grading Date:………..
o R0 No DR o R1 Mild NPDR
o R2 Moderate NPDR o R2 Severe NPDR
o R3 PDR o R3 Pre-retinal fibrosis ±
tractional RD
o M0 No Maculopathy o M1 Diabetic Maculopathy
o OL diagnosis:………………………...
Consultation Outcome
o Annual Screening date o FU in Retina Clinic date
o Laser Rx date o FFA/OCT date
o IV injection date o Operation date
o Did Not Attend (DNA)