Practice Location Selection:
Select a Practice
Configuration
Step 1:  Patient Assessment
Does your patient have Wet AMD?
Does your patient have geographic atrophy?
Is the geographic atrophy subfoveal?
Does the patient have drusen in the left eye?
Select
No <63μm 63-125μm ≥125μm
Does the patient have drusen in the right eye?
Select
No <63μm 63-125μm ≥125μm
Does your patient pigmentary changes in either eye?
Select
Left Eye Right Eye Both Neither
Does your patient have normal dark adaptation curve?
Type of pigment changes?
Patient's AMD severity is
Subclinical
Subclinical Early Moderate Advanced
Risk of developing Advanced AMD:
Next 5 Years
Next 10 Years
0%
0%
LOW RISK
Change suggested supplement: 
MacuHealth
✖ Reset All Next
Based on the above information the following is a suggested patient care follow-up plan
Genetic Testing
Contrast
Amsler Grid
Please refer to a specialist
Normal Aging, No AMD
Step 2:  Patient Overview
Diagnosis
Patient's AMD severity is
Subclinical
Risk of developing Advanced AMD:
Next 5 Years
Next 10 Years
0%
0%
LOW RISK
Next Steps
Based upon the evidence, your doctor has prescribed
None Supplement
Based upon the evidence and your risk for progression,
your doctor will monitor you Every 6 months
If you have trouble reading, driving or recognizing faces this may be a sign that AMD has progressed.
Please call our office immediately if vision changes occur.
Learn More
What is Age-related Macular Degeneration (AMD)?
  • The leading cause of vision loss in people 50+ years
  • Vision loss often occurs gradually over time
  • Poor night vision is an early symptom

Types of AMD
There are two types of AMD: Dry AMD (more common) and Wet AMD (usually more severe). Most AMD starts as dry and in 10 - 20% of individuals can progress to wet.
Wet AMD leads to bleeding and swelling in the back of the eye, this is treated with injections.
Treatment
Unfortunately, there is no cure for AMD. Age and family history are the most important risk factors. However, there are several things that can be done to reduce the risk of progression and vision loss.

  • Don't smoke
  • Eat healthy food as fruits and vegetables
  • Increase your Omega-3 fatty acids
  • Exercise regularly
  • Wear sunglasses that blocks UV light
  • Take vitamins help reduce the risk of AMD progression
AMD Eye Examination Report
Patient
Name:
DOB:
/
/
Address:
Phone:
Family / General Practice Physician
Name:
Address:
Phone:
Fax:
Other Coordinating Physician
Name:
Address:
Phone:
Fax:
This patient received an eye examination on with the following results.
Diagnosis
Patient's AMD severity is
Subclinical
Risk of developing Advanced AMD:
Next 5 Years
Next 10 Years
0%
0%
LOW RISK
Next Steps
Based upon the evidence, I have prescribed
MacuHealth Supplement
Based upon the evidence and the patients risk for progression,
I will monitor the patient Every 6 months
Dilated Fundus Evaluation:
Testing to monitor for progression will include:
I have discussed the following things that can be done to reduce the risk of progression and vision loss:
  • Don't smoke
  • Eat healthy food as fruits and vegetables
  • Increase your Omega-3 fatty acids
  • Exercise regularly
  • Wear sunglasses that blocks UV light
  • Take vitamins help reduce the risk of AMD progression
Comments:
Next appt date (if avail):
/
/
Signature:
/
/
Note - If faxed, this report must include the HIPPA Privacy Rule fax cover sheet
© 2020 Vision Source ® L.P. All rights reserved.
{{OfficeName}}
{{Supplement}}