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Annual Ophthalmologist Checklist Mobile App

The Annual Ophthalmologist Checklist mobile app is part of the Federal Diabetes Exemption Program. The app covers Driver Identifying Information and Federal Diabetes Standards Annual medical monitoring and reporting as a condition of the exemption from the diabetes standard of 49 CFR 391.41(b)(3). An applicant with diabetic retinopathy must be evaluated by an ophthalmologist. The vision examination must occur AFTER any eye surgery/procedures (postoperatively). A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com. If you would like to enable HIPAA on your GoCanvas account please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save”

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the Annual Ophthalmologist Checklist Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    Federal Diabetes Exemption Program

  • Ico textbox

    Driver Identifying Information

  • Ico textbox

    Name:

  • Ico multiline

    Address:

  • Ico date

    DOB

  • Ico statictext

    This individual was granted an exemption from the Federal diabetes standard to operate a commerci...

  • Ico statictext

    PLEASE CHECK / FILL IN REQUESTED INFORMATION.

  • Ico checkbox

    I am an ophthalmologist

  • Ico checkbox

    I am an optometrist

  • Ico date

    Date of most recent examination:

  • Ico statictext

    Distant visual acuity (please provide both if applicable):

  • Ico checkbox

    UNCORRECTED

  • Ico integer

    Right eye: 20/_____

  • Ico textbox

    Left eye: 20/_____

  • Ico checkbox

    CORRECTED

  • Ico checkbox

    Glasses

  • Ico checkbox

    Contact Lens

  • Ico integer

    Right eye: 20/_____

  • Ico integer

    Left eye: 20/_____

  • Ico statictext

    Please record the interpreted results in degrees of horizontal field of vision for each eye.

  • Ico decimal

    Right eye: ___________degrees

  • Ico decimal

    Left eye: ___________degrees

  • Ico textbox

    Test used to determine:

  • Ico statictext

    *Note: If the patient has received laser treatment, and in your medical opinion you believe the p...

  • Ico dropdown

    Does the patient have diabetic retinopathy?

  • Ico statictext

    If yes:

  • Ico checkbox

    Proliferative

  • Ico checkbox

    Stable

  • ...and More!

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