Ku - Annual Comprehensive Diabetes Foot Exam Form
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1
2Developed by JoAnn M. Peterson, MSN, ARNP
5/19/09
Annual Comprehensive Diabetes Foot Exam Form
Name ____________________________________________DOB _________________ Date ________________
Wt ______ Ht ______ BP ______ Pulse ______ Temp _____ BMI ______ Allergies _________________________
Interview
Current/Past History
Symptoms
DM Complications
Current tobacco user
Neuropathic sx:
Renal (dialysis, transplant)
History of tobacco use – Last used
Burning or shooting pain, electrical or
Retinal (visual impairment)
tobacco products ____________________
sharp sensations, etc.
________________________________
Ulcerations
Numbness, tingling
Comments:
Charcot joint
Sweating of feet
Cardiovascular disease
________________________________
Vascular surgery
Angioplasty
Vascular sx:
Hx of foot amputations (date, side, level)
Pain in calf muscles when walking that is
_________________________________
relieved with rest
Self Care
Other foot surgeries (specify) __________
Pain in feet, especially at night, that is
Able to see the bottom of feet
_________________________________
improved by hanging them over the side
(visually/mobility)? __________________
DM Type 1
Yr Dx’d w______________
of the bed
Wears special shoes or told needs special
DM Type 2
Diet only
Oral meds
Pain at rest
foot wear?
Requires insulin
Swelling in legs
Checks feet daily
Comments:
“End of the Day Achy Syndrome”
Able to trim own nails or has trained,
Nonhealing ulcer
Reliable person trimming nails
_________________________________
Ambulation:
Unlimited
Community
Comments:
Homebound
Non-ambul
Comments:
Clinical Findings
Derm: (use key and diagram in right column)
Measure, draw in, label foot abnormalities. Use following key for
Skin of lower legs thin, fragile, shiny, brawny, thickened, hairless,
skin conditions: C = Callus
U = Ulcer
PU = Pre-ulcer
D = Dryness
F = Fissure
M = Maceration
edema, etc __________________________________________
Presence of dryness, fissures, cracking, skin thickening
R = Redness
S = Swelling
T = Tinea
Areas of abnormal erythema
Temp differences
Sweating of feet
Presence of ulcers
Callus(es)
Callus(es) with hemorrhage
Maceration between toes
Fungal infection
Nails thick, discolored, dysmorphic – circle abnormal nails on
diagram in right column
____________________________________________________
Musculoskelatal Deformities:
L
R
Bunions (Hallus Valgus)
Hammer toes
Foot drop
Right
Left
Claw toes
Prominent metatarsal heads
Charcot foot
Comments:
Muscle wasting/guttering between metatarsals
Other:
(Con’t on back)
Andrew J M Boulton, David G Armstrong, Stephen F Albert, Robert G Frykberg, et.al. (2008). Comprehensive Foot Examination and Risk Assessment: A
report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical
Endocrinologists. Diabetes Care, 31(8), 1679-85.
5/19/2009
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