Diabetes Foot Screen Instructions
Section 1:
The twelve questions can be answered in the ‘R’ (right foot) or ‘L’ (left foot) blank
with a ‘Y’ or ‘N’ to indicate a positive or negative finding. Fill in all blanks.
Question 1: Is there a history of foot ulcer?
Question 2: Is there a foot ulcer now?
The purpose of these questions is to determine if the patient currently has or has
ever had an ulcer on the foot. History of a foot ulcer places the patient at an
increased risk of developing another foot ulcer and increases the potential of
future amputation. The patient with a past or present foot ulcer is considered
permanently in Risk Category 3.
Question 3: Is there toe deformity?
Question 4: Is there an abnormal shape of the foot?
This is determined by inspecting the general shape of the patient’s foot.
Conditions to consider include: prominent bony areas, partial or complete
amputations of the foot or toes, clawed toes, bunions, or "Charcot Foot".
A Charcot Foot is a neuropathic foot may present with swelling, increased
temperature, and little or no pain. Advanced cases show progressive signs of
deformity into what is referred to as a "rocker bottom" or "boat shaped" foot. A
patient with a Charcot Foot is permanently in Risk Category 3.
Question 5: Are the toenails thick or ingrown?
Identify Mycotic, significantly hypertrophic or ingrown nails.
Question 6: Is there callus buildup?
Identify focal and/or heavy callous.
Question 7: Is there swelling?
Swelling may stem from a variety of causes such as a Charcot fracture, infection,
or “venous stasis”.
Question 8: Is there elevated skin temperature?
Elevated, localized skin temperature can indicate excessive mechanical stress,
bone fracture, or an infection and requires further evaluation. Skin temperature
can be measured by a commercially available thermometer or by touch. A
temperature elevation of greater than 2 degrees centigrade on the thermometer
or a noticeable difference by touch when compared with the contralateral foot is
considered clinically significant.
Question 9: Is there muscle weakness?
A manual muscle test of foot and great toe dorsi and plantar flexion.