Comprehensive Diabetes Foot Examination Form printable pdf download

Comprehensive Diabetes Foot Examination Form

Adapted from the National Diabetes Education Program’s Foot Screening Form

Name:

Date:

Age:

Diabetes Type □ 1 □ 2

Current Treatment: □ Diet □ Oral □ Insulin

Age at Onset:

I. Medical History

II. Current History

(Check all that apply.)

1. Any change in the foot or feet since the last evalua-

tion?

□ Peripheral Neuropathy

□ Yes □ No

□ Cardiovascular Disease

2. Current ulcer or history of a foot ulcer?

□ Nephropathy

□ Yes □ No

□ Retinopathy

3. Is there pain in the calf muscles when walking that is

□ Peripheral Vascular Disease

relieved by rest?

□ Yes □ No

III. Foot Exam

IV. Sensory Foot Exam

1. Are the nails thick, too long, ingrown or infected with fungal disease?

Label sensory level with a “+” in the five circled areas of

the foot if the patient can feel the 5.07 Semmes-

□ Yes □ No

Weinstein (10-gram) nylon filament and “-” if the patient

cannot feel the filament.

2. Note foot deformities.

□ Toe deformities □ Bunions

□ Charcot foot

□ Foot drop

NOTES

□ Prominent metatarsal heads

□ Amputation (Specify date, side and level.)

3. Pedal Pulses

(Fill in the blanks with a “P” or an “A” to indicate present or absent.)

Posterior tibial:

Dorsalis pedis:

Left

Right

4. Skin Condition (Measure, draw in and label the patient’s skin condi-

tion using the key and foot diagram to the right.)

C = Callus R = Redness W = Warmth

F = Fissure S = Swelling U = Ulcer

M = Maceration PU = Pre-ulcerative lesion D = Dryness

V. Risk Categorization (Check appropriate item.)

High-Risk Patient

Low-Risk Patient

One or more of the following:

All of the following:

□ Loss of protective sensation

□ Intact protective sensation □ No severe deformity

□ Absent pedal pulses

□ No prior foot ulcer

□ Pedal pulses present

□ Severe foot deformity

□ No severe deformity

□ No amputation

□ History of foot ulcer

VI. Footwear Assessment

VII. Education

1. Does the patient wear appropriate shoes?

1. Has the patient had prior foot care education?

□ Yes □ No

2. Does the patient need inserts/orthotics?

2. Can the patient demonstrate appropriate self-care?

□ Yes □ No

VII. Management Plan (Check all that apply.)

□ Provide patient education for preventive foot care.

□ Refer to an APMA member podiatrist or an appropriate physician.

Date:

Provider Signature:

Comprehensive Diabetes Foot Examination Form

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