Diabetic Exam Form Patient Name First Last Date of Birth MM slash DD slash YYYY Primary Care PhysicianName First Last Address Street Address City State / Province / Region ZIP / Postal Code Phone NumberFax NumberSelect: Type 1 Type 2 How many years have you been diagnosed as a diabetic? Taking Insulin? Yes No Value of last A1C Date it was taken Value of most recent fasting blood sugar When was it taken? Do you self monitor every morning? Yes No HiddenDo you self monitor every morning? I would like to receive an updated prescription for glasses during my visit for $45 Yes No You Should Know!Please be advised that as part of your diabetic eye exam, your pupils will need to be dilated for a thorough evaluation of your eye health. This procedure is a standard part of this type of examination and is necessary for the detection of potential vision-threatening conditions. Additionally, this visit will be billed to your medical insurance and not your vision plan. Thank you for your understanding.