Get the free Dilated Eye Exam Form

This form is used to assess the eye health of applicants seeking to participate in boxing, kickboxing, and other combat sports regulated by the North Carolina Boxing and Combat Sports Commission.

How to fill out dilated eye exam form

How to fill out dilated eye exam form

1. Begin by entering your personal information such as name, date of birth, and contact details at the top of the form.
2. Provide your medical history, including any current medications and previous eye conditions.
3. Indicate any allergies you may have, particularly to eye drops or medications.
4. Summarize your vision history, noting any changes in vision or recent symptoms.
5. Complete the section on family eye history, detailing any relevant conditions in immediate family members.
6. Sign the form at the designated area, confirming that the information provided is accurate.

Who needs dilated eye exam form?

1. Individuals experiencing vision problems, such as blurred vision or difficulty seeing at night.
2. People with a family history of eye diseases, such as glaucoma or macular degeneration.
3. Patients diagnosed with diabetes who require regular eye examinations.
4. Anyone over the age of 60, as age increases the risk of eye-related conditions.
5. Individuals who have had eye injuries or surgeries and need follow-up examinations.

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What is dilated eye exam form?

A dilated eye exam form is a document used to record the results and observations from a comprehensive eye exam where pupil dilation is performed to allow a better view of the eye's interior.

Who is required to file dilated eye exam form?

Healthcare providers, particularly eye care professionals, are required to file a dilated eye exam form for patients undergoing a dilated eye exam.

How to fill out dilated eye exam form?

To fill out a dilated eye exam form, the healthcare provider should include the patient's personal information, the date of the exam, the findings from the examination, recommended treatments or follow-ups, and any pertinent medical history.

What is the purpose of dilated eye exam form?

The purpose of the dilated eye exam form is to document the findings of the eye examination, enhance patient care by providing a record for future reference, and to fulfill legal and insurance requirements.

What information must be reported on dilated eye exam form?

The dilated eye exam form must report patient identification information, details of the exam conducted, findings such as retinal health, any abnormalities detected, and recommendations for further treatment or monitoring.