This age-related macular degeneration screening template is designed for ophthalmologists, optometrists, and other eye care teams that need a clear intake process for patients reporting possible central vision changes. It combines basic patient details with focused screening questions so staff can review symptoms, duration, progression, and which eye is affected before the visit or referral decision.
The form includes prompts about common AMD-related concerns such as blurred central vision, difficulty reading or recognizing faces, wavy lines, dark or empty central areas, reduced color vividness, and increased need for bright light. It also captures whether the patient has completed an Amsler grid test and records separate right-eye and left-eye observations, which helps organize findings in a way that is easy to review.
As a client intake form, this template gives practices a structured starting point for early screening workflows, follow-up evaluations, and retinal specialist referrals. It can also be adapted into a broader patient intake form for healthcare settings that want to gather additional history, risk factors, insurance details, or clinical notes alongside vision screening responses.
