Age-Related Macular Degeneration Screening Form

Age-related macular degeneration (AMD) is one of the leading causes of vision loss in adults over 50, affecting millions worldwide. Early detection through regular screening can make a significant difference in preserving sight and quality of life. This AMD screening form provides healthcare professionals with a structured, efficient way to assess patient risk factors, document visual symptoms, and determine when specialist referral is needed.

Comprehensive AMD Risk Assessment

This template guides patients through a thorough evaluation of AMD risk factors including age, family history, smoking status, cardiovascular health, and dietary habits. By capturing this information upfront, eye care professionals can quickly identify high-risk individuals who may benefit from more frequent monitoring or preventive interventions.

The form includes dedicated sections for documenting current visual symptoms—from blurred central vision and difficulty reading to distorted lines and dark spots—helping clinicians distinguish between early warning signs and more advanced AMD presentations.

Amsler Grid Self-Testing Integration

One of the form's key features is the inclusion of Amsler grid testing instructions and results documentation. Patients can perform this simple self-test at home or in the office and report any distortions, missing areas, or wavy lines they observe. This quick screening tool is invaluable for detecting subtle changes in central vision that might otherwise go unnoticed between appointments.

Streamlined Referral Pathway

When screening results indicate potential AMD or significant risk factors, the form facilitates seamless referral to retinal specialists. Healthcare providers can use the collected information to make informed referral decisions and ensure patients receive timely specialist care when needed.

Built with Paperform's intuitive form builder, this template can be easily customized to match your practice's branding and workflow. Submissions integrate directly with your existing systems through Stepper (stepper.io) workflows—automatically sending referral notifications, updating patient records in your EHR, or triggering follow-up appointment scheduling.

Whether you're an optometrist, ophthalmologist, primary care physician, or work in a community health setting, this AMD screening form helps you deliver proactive, organized eye care that can make a real difference in your patients' vision outcomes.