"Comprehensive Diabetes Foot Examination Form - American Brace & Limb Enterprise, Llc"

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Comprehensive Diabetes Foot Examination Form
Name:
Age:
Date:
Current Treatment:
Age at Onset:
Diabetes Type
1
2
Diet
Oral
Insulin
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
Retinopathy
Yes
No
Cardiovascular Disease
Peripheral Vascular Disease
2. Current ulcer or history of a foot ulcer?
Nephropathy
Yes
No
3. Is there pain in the calf muscles when walking that is
Most recent hemoglobin A1c results ________% __________ date
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 monofilament and “-” if the
patient cannot feel the filament.
2. Note foot deformities.
Toe deformities
Bunions
Charcot foot
Foot drop
(Measure, draw in and lable the patient's skin condition)
Prominent metatarsal heads
(C) = Callus (R) = Redness (W) = Warmth
(F) = Fissure (S) = Swelling (U) = Ulcer
Amputation (Specify date, side and level.)
(M = Maceration (PU) = Pre-ulcerative lesion
(D) = Dryness
3. Pedal Pulses
(Fill in the blanks with a “P” or an “A” to indicate present or absent.)
Posterior tibial:
Dorsalis pedis:
Left
Left
Right
Right
4. Is the skin thin, fragile, shiny and hairless?
Yes
No
5. Is there evidence of callus formation?
Yes
No
6. Are there signs of pre-ulceration?
Yes
No
7. Any blood or discharge on the socks or hose?
Yes
No
V. Risk Categorization (Check appropriate item.)
High-Risk Patient One or more of the following:
Low-Risk Patient
Loss of protective sensation
All of the following:
Absent pedal pulses
Intact protective sensation
Pedal pulses present
F oot deformity
No prior foot ulcer
No amputation
History of foot ulcer
No foot deformity
Previous Amputation
VI. Footwear Assessment
VII. Education
1. Does the patient wear appropriate shoes?
1. Has the patient had prior foot care education?
Yes
No
Yes
No
2. Does the patient need diabetic shoes/ inserts?
2. Can the patient demonstrate appropriate foot-care?
Yes
No
Yes
No
Vascular Laboratory
VIII. Management Plan (Check all that apply)
Diagnostic studies:
Hemoglobin A1c
Provide patient education for preventative foot care.
Date:
Other _________________
Provide patient education about HbA1c or other aspect of self-care.
Date:
Provider Signature:
American Brace & Limb Enterprise, LLC 1044 S. Cumberland Street Morristown, TN 37813 Phone: 423.318.8824 Fax: 423.318.2872
Comprehensive Diabetes Foot Examination Form
Name:
Age:
Date:
Current Treatment:
Age at Onset:
Diabetes Type
1
2
Diet
Oral
Insulin
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
Retinopathy
Yes
No
Cardiovascular Disease
Peripheral Vascular Disease
2. Current ulcer or history of a foot ulcer?
Nephropathy
Yes
No
3. Is there pain in the calf muscles when walking that is
Most recent hemoglobin A1c results ________% __________ date
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 monofilament and “-” if the
patient cannot feel the filament.
2. Note foot deformities.
Toe deformities
Bunions
Charcot foot
Foot drop
(Measure, draw in and lable the patient's skin condition)
Prominent metatarsal heads
(C) = Callus (R) = Redness (W) = Warmth
(F) = Fissure (S) = Swelling (U) = Ulcer
Amputation (Specify date, side and level.)
(M = Maceration (PU) = Pre-ulcerative lesion
(D) = Dryness
3. Pedal Pulses
(Fill in the blanks with a “P” or an “A” to indicate present or absent.)
Posterior tibial:
Dorsalis pedis:
Left
Left
Right
Right
4. Is the skin thin, fragile, shiny and hairless?
Yes
No
5. Is there evidence of callus formation?
Yes
No
6. Are there signs of pre-ulceration?
Yes
No
7. Any blood or discharge on the socks or hose?
Yes
No
V. Risk Categorization (Check appropriate item.)
High-Risk Patient One or more of the following:
Low-Risk Patient
Loss of protective sensation
All of the following:
Absent pedal pulses
Intact protective sensation
Pedal pulses present
F oot deformity
No prior foot ulcer
No amputation
History of foot ulcer
No foot deformity
Previous Amputation
VI. Footwear Assessment
VII. Education
1. Does the patient wear appropriate shoes?
1. Has the patient had prior foot care education?
Yes
No
Yes
No
2. Does the patient need diabetic shoes/ inserts?
2. Can the patient demonstrate appropriate foot-care?
Yes
No
Yes
No
Vascular Laboratory
VIII. Management Plan (Check all that apply)
Diagnostic studies:
Hemoglobin A1c
Provide patient education for preventative foot care.
Date:
Other _________________
Provide patient education about HbA1c or other aspect of self-care.
Date:
Provider Signature:
American Brace & Limb Enterprise, LLC 1044 S. Cumberland Street Morristown, TN 37813 Phone: 423.318.8824 Fax: 423.318.2872