Annual Diabetes Foot Exam Form
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1ANNUAL DIABETES FOOT EXAM FORM
Patient’s Name: ___________________________________ Exam Date: ______________
Type I
Type II
Ht: _______ Wt: _______ DOB: _____________
DM:
Draw pattern on foot where there is:
FOOT EXAM
R=redness; S=swelling; W=warmth; D=Dryness; M=maceration
(If abnormal circle which foot)
No
Lt
Rt
(+) Can feel nylon filament; (-) Cannot feel nylon filament
Current Foot Ulcer(s)
Callus
Pre-ulcer
Ulcer
History of Foot Ulcer(s)
Abnormal Foot Shape
Toe deformity (bunion, hammer toes…)
Callus Buildup
History of callusing
Edema
Elevated temperature
Lower extremity pain
Previous amputation
Blister/ Laceration
Can patient see plantar foot?
Does patient use appropriate footwear?
VASCULAR FINDINGS
Non
Acceptable
Acceptable
Dorsalis Pedis Pulse
Posterior Tidial Pulse
Foot Hair Growth
Capillary Refill
Cold feet
Claudications
Pallor
RECOMMENDATIONS
Yes
No
Therapeutic shoes
Orthotic Inserts
( ) Heat-moldable ( ) Custom
Sensations
Additional Comments:
This is a part of a comprehensive plan for the treatment of this patient’s diabetes.
___________________________________
________________
Physician Signature:
Date:
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Parent category: Medical