Diabetic Foot Examination Please enable JavaScript in your browser to complete this form.patient name *ID number *Phone *Chief Complaint *Here for diabetic foot evaluation and counselingAdditional question (s) or concern(s) ?Diabetic x number of years *Type of diabetes *Type oneType twopre diabetesGDMNAPt can't recognized the typeLast A1c *Start the Exam?is there any issue with feet YesNoNumbness *YesNo Pain *YesNo Ulcers *YesNo DateCalluses *YesNo Fungus *YesNo Dryness of Skin *YesNo Is there an abnormal shape of foot? *YesNoIs there toe deformity? *YesNoAre the toenails thick or ingrown? *YesNoIs there elevated skin temperature? *YesNoIs the patient wearing improperly fitting shoes? *YesNoDoes the patient use footwear inappropriate for category? *YesNoCan the patient see bottom of feet? *YesNoIndicate the level of sensation in the circles:Can feel the 10 gram nylon filamentCannot feel the 10 gram nylon filamentImpression .0 No loss of protective sensation.1 Loss of protective sensation with no weakness, deformity, callus, pre-ulcer or history of ulceration.2 Loss of protective sensation with weakness, deformity, pre-ulcer or callus but no history of ulceration or poor circulation3 History of plantar ulceration or neuropathic fractureCheckboxes.File Upload Drag & Drop Files, Choose Files to Upload Indicate the level of sensation in the circles: Clear Signature Follow-upSignatureCertified Diabetic EducatorRNDate Send
