Annual Comprehensive Diabetes Foot Exam Form

Name:

Date:

ID #:

I. Presence of Diabetes Complications

1. Check all that apply.

_____ Peripheral Neuropathy
_____ Nephropathy
_____ Retinopathy
_____ Peripheral Vascular Disease
_____ Cardiovascular Disease
_____ Amputation (Specify date, side, and level)
 

Current ulcer or history of a foot ulcer?
Y____ N____

For Sections II & III, fill in the blanks with “Y” or “N” or with an “R,” “L,” or “B” for positive findings on the right, left, or both feet.

II. Current History

1. Is there pain in the calf muscles when walking that is relieved by rest?
Y____ N____

2. Any change in the foot since the last evaluation?
Y____ N____

3. Any shoe problems?
Y____ N____

4. Any blood or discharge on socks or hose?
Y____ N____

5. Smoking history?
Y____ N____

6. Most recent hemoglobin A1c result
______ %____________ date

III. Foot Exam

1. Skin, Hair, and Nail Condition

Is the skin thin, fragile, shiny and hairless?
Y____ N____

Are the nails thick, too long, ingrown, or infected with fungal disease?
Y____ N____
 

Measure, draw in, and label the patient’s skin condition, using the key and the foot diagram below.
C=Callus U=Ulcer PU=Pre-Ulcer F=Fissure M=Maceration R=Redness S=Swelling W=Warmth D=Dryness

2. Note Musculoskeletal Deformities
_____ Toe deformities
_____ Bunions (Hallus Valgus)
_____ Charcot foot
_____ Foot drop
_____ Prominent Metatarsal Heads
 

3. Pedal Pulses
Fill in the blanks with a “P” or an “A” to indicate present or absent.

Posterior tibial: Left _____ Right _____

Dorsalis pedis: Left _____ Right _____
 

4. Sensory Foot Exam Label sensory level with a “+” in the five circled areas of the foot if the patient can feel the 5.07 (10-gram) Semmes-Weinstein nylon monofilament and “-” if the patient cannot feel the filament.

Notes for Right Foot:

Notes for Left Foot:

IV. Risk Categorization

Check appropriate box.

V. Footwear Assessment

Indicate yes or no.

1. Does the patient wear appropriate shoes? Y____ N____

2. Does the patient need inserts? Y____ N____

3. Should corrective footwear be prescribed? Y____ N____

VI. Education

Indicate yes or no.

1. Has the patient had prior foot care education? Y____ N____

2. Can the patient demonstrate appropriate foot care? Y____ N____

3. Does the patient need smoking cessation counseling? Y____ N____

4. Does the patient need education about HbA1c or other diabetes self-care? Y____ N____

VII. Management Plan

Check all that apply.

1. Self-management education:
Provide patient education for preventive foot care. Date:___________________
Provide or refer for smoking cessation counseling. Date:___________________
Provide patient education about HbA1c or other aspect of self-care. Date: ___________________
 

2. Diagnostic studies:

_____ Vascular Laboratory
_____ Hemoglobin A1c (at least twice per year)
_____ Other: ________________________
 

3. Footwear recommendations:
_____ None
_____ Athletic shoes
_____ Accommodative inserts
_____ Custom shoes
_____ Depth shoes
 

4. Refer to:
_____ Primary Care Provider
_____ Diabetes Educator
_____ Podiatrist
_____ RN Foot Specialist
_____ Pedorthist
_____ Orthotist
_____ Endocrinologist
_____ Vascular Surgeon
_____ Foot Surgeon
_____ Rehab. Specialist
_____ Other: ________________________
 

5. Follow-up Care:
Schedule follow-up visit. Date: ________________________

Provider Signature: _______________________________

National Diabetes Education Program (NDEP)    http://ndep.nih.gov
NIDDK, National Institutes of Health, Bethesda, MD

A Joint Initiative of the National Institutes of Health and the
Centers for Disease Control and Prevention