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.
R
L
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
___________________________________________

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