Appendix 1 (Part 1): Diabetic Foot Evaluation pdf

S–50 THE JOURNAL OF FOOT & ANKLE SURGERY
Patient:
Chart #
Date:
Age:
Diabetes duration
Attending MD
Height Weight
BP HbA1C
Type 1
Type 2
Rx - Insulin
- Incretin
-
- Diet
Oral Hypoglycemic
Skin:
Lesions
Nails
Turgor
Color
Temperature
Texture
Fissures
Corns
Calluses
Ulcers
Musculoskeletal
Joint Flexibility
Deformities
or Sites of

High Pressure
Gait assessment
History of:
Foot Ulcer
Infection
Amputation
Revascularization
Renal Disease
CAD
Stroke
Tobacco
Alcohol
Shoes
Paresthesia/Tingling
Numbess
Burning
Sharp Pain
Night Pain
Muscle Weakness
Gait Difficulties
Claudication
Diabetic Foot Evaluation
Mark areas of callus, ulcer or pre-ulcer,
erythema, swelling, tenderness or deformity
Medications:
toes
plantar
feet to above ankle
to below knee
night

daily
occasionally
wheelchair
walker
cane
brace
foot orthosis
MDI
Appendix 1 p1
Prior Ulceration &/or Amputation
Charcot Deformity - Location
__
__
0 +1 +2 +3 0 +1 +2 +3
0 +1 +2 +3 0 +1 +2 +3
Absent Present Absent Present
Absent Present Absent Present
<1 1-3 >3 <1 1-3 >3
Absent
Patella
Achilles
Right Left
Deep Tendon Reflexes (+Present; - Absent)
Vascular Exam
Pulses:
Dorsalis Pedis
Posterior Tibial
Elevation Pallor
Dependent Rubor
Capillary Filling Time

Edema
Neurologic Exam
Right
Left
Pulse Exam
Examiner:
Date:
Periodic Foot Care
Extra Depth Shoes
Multiple Density Insoles (MDI), Orthotics
Bracing
Vascular Testing: Doppler
Consultation:
Other: Diabetic Education
Recommended Management:
Left
Right
- Sensory Semmes-Weinstein Monofilament
Ability to detect 5.07 or 10 gm Monofilament: + or -
Risk Status
0 No Sensory Neuropathy, No PAD,
Negative Hx of Foot Ulcer
I Neuropathy (LOPS), No PAD, No Deformity
II Sensory Neuropathy + PAD &/or
Foot Deformity
III Previous Foot Ulcer or Amputation
0 absent
+1 diminished
+2 normal
+3 bounding

DIABETIC FOOT DISORDERS VOLUME 45, NUMBER 5, SEPTEMBER/OCTOBER 2006 S–51
Appendix 1 p2