|
Name:__________________________________________
|
CHECK BOTH FEET
|
|
ID#: ________ Phone #:_____________________
|
(Circle correct response) |
|
Facility: _______________________________
|
|
DOB (dd/mm/yy):_______/_______/_______
|
|
Gender: M □ F □ Years with diabetes:________
|
“YES” on either foot = HIGH RISK
|
|
Ethnicity: Black □ Asian □ Caucasian □ Mixed □ Other
|
LEFT
|
RIGHT
|
|
Date of Exam (dd/mm/yy): ______/______/______
|
|
HISTORY
|
1. Previous ulcer |
NO YES |
NO YES |
|
2. Previous amputation |
NO YES |
NO YES |
|
PHYSICAL EXAM
|
3. Deformity |
NO YES |
NO YES |
|
4. Ingrown toenail (thickened nail fold) |
NO YES |
NO YES |
|
5.Absent pedal pulses (Dorsalis Pedis and/ or Posterior Tibial) |
NO YES |
NO YES |
|
FOOT LESIONS
Remember to check 4th and 5th web spaces/nails for fungal infection and check for inappropriate footwear. |
6. Active ulcer |
NO YES |
NO YES |
|
7. Blisters |
NO YES |
NO YES |
|
8. Calluses (thick scale on plantar skin) |
NO YES |
NO YES |
|
9. Fissure (linear crack) |
NO YES |
NO YES |
|
NEUROPATHY
MORE THAN 4/10 SITES LACKING FEELING =
“YES”
|
10. Monofilament exam (record negative reaction):
|
NO YES |
NO YES |
|
a)Right______/10 negatives |
| (4 negatives = Yes) |
|
b) Left_______/10 negatives |
Total # of YES:_____
|
Total # of YES: ____
|
| (4 negatives = Yes) |
|
PLAN
|
|
a) POSITIVE SCREEN- Results when there are one or more “Yes” responses. Refer to a foot specialist or team for prevention, treatment and follow up. (Bony deformity, current ulcer, absent pulse are most urgent). These individuals are at increased risk of a foot ulcer and/or infection. Patients should be educated on what changes to observe and report, while waiting for the specialist appointment. |
|
Referral to: ____________________________ Appointment time:_______________________ |
|
b) NEGATIVE SCREEN- Results when there are all “No” responses. No referral required. Educate patient to report any new changes to their healthcare provider and re-examine in 1 year. |
|
One Year Date for Re-Examination (dd/mm/yy):________/________/________
|
|
Completed By: __________________________ Date: _________________________________
|
|
Additional Note:
|
| For POSITIVE SCREEN, in addition to referral plan above, positive risk factors can be linked to the care recommendations in “Root Risk Classification and Follow- Up Guide” table on the bottom of reverse side. Local referral patterns may vary depending on expertise and available resources |
