Diabetes Foot Screen - Hrsa printable pdf download

Diabetes Foot Screen - Hrsa

Diabetes Foot Screen

Name (Last, First, MI) _____________________________ Date: _____/_____/_____

Fill in the following blanks with a "Y" or "N" to indicate findings in the right or left foot.

Is there a history of a foot ulcer?

_______

Is there a foot ulcer now?

_______

Is there a claw toe deformity?

_______

Is there swelling or an abnormal foot shape?

_______

Is there elevated skin temperature?

_______

Is there limited ankle dorsiflexion

_______

Are the toenails long, thick or ingrown?

_______

Is there heavy callous build-up?

_______

Is there foot or ankle muscle weakness?

_______

Is there an absent pedal pulse?

_______

Can the patient see the bottom of their feet?

_______

Are the shoes appropriate in style and fit?

_______

Note the level of sensation in the circles:

= Can feel the 5.07 filament

— = Can't feel the 5.07 filament

RIGHT

LEFT

Skin Conditions on the Foot or Between the Toes:

Draw in: Callous

, Pre-ulcer

, Ulcer

(note length and width in cm)

Label with: R - redness, M - maceration, D - dryness, T - Tinea

RISK CATEGORY:

____ 0 No loss of protective sensation.

____ 1 Loss of protective sensation

____ 2 Loss of protective sensation with either high pressure (callous/deformity), or poor circulation.

____ 3 History of plantar ulceration, neuropathic fracture (Charcot foot) or amputation.

Performed by

___________________________________________

Diabetes Foot Screen - Hrsa

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