<<PRACTICE LETTERHEAD>>

Surname: <<Patient Demographics:Surname>>
First Name: <<Patient Demographics:First Name>>	Date of Visit: <<Miscellaneous:Date>>
Filled in By: <<Miscellaneous:Current User>>	
Diabetic Foot Screening	
Vascular Status                           Right                                            Left                                           	
Foot Pulse
            Dorsalis Pedis        p
            Tibialis Posterior   p	Palpable                         p
Impalpable                     p
Audible with Doppler    p	Palpable                         p
Impalpable                     p
Audible with Doppler    p	
Pulse Type	Bounding                       p    
Weak                             p
Normal                          p	Bounding                       p    
Weak                             p
Normal                          p	
Symptoms of Vascular Disease	Claudication       Yes     p No    p
Rest Pain            Yes     p No    p	
Neuropathy Status                     Right                                             Left                                           	
Reflexes	Present                          p
Absent                           p
Missing Limb                p
Not Done                       p	Present                          p
Absent                           p
Missing Limb                p
Not Done                       p	
Monofilament	Can feel at both sites     p
Cannot feel                    p	Can feel at both sites     p
Cannot feel                    p	
Previous Foot Ulcer	Yes     p No    p
Site:
Year:	Yes     p No    p
Site:
Year:	
Previous Foot Amputation	Yes     p No    p
Site:
Year:	Yes     p No    p
Site:
Year:	
Symptoms of Neuropathy
(please tick, if yes)	Pain                         p  Numbness       p
Pins & Needles       p  Burning           p	
 Foot Pathology                                                                                                                                   	
Skin	Normal                 p  Fissured                       p
Dry                       p	
Callus	Nil                        p  Local                            p
Diffuse       p  Haemorrhagic Callus   p	
Fungal Infections	Nil                        p  Interdigital                   p
On foot                 p                	
Corns	Yes                          p  No                        p	
Interdigital Areas	Normal                    p  Macerated            p	
Nails	Normal                    p  Ingrown                p
Thickened               p  Fungal                   p   	
Foot Shape	Claw Toe                p  Bony Prominences p
High Arch               p	
Footwear
(if inappropriate, please state why)	Appropriate            p
Inappropriate     p ______________________________
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Assess Education Need                                                                                                                       	
Does the patient understand the effects of diabetes on foot health?	Yes           p  No         p	
Can the patient identify appropriate foot care practices?	Yes           p  No         p	
Are the patient's feet adequately cared for?	Yes           p  No         p	
Assess Self Care Capacity                                                                                                                  	
Does the patient have impaired vision?	Yes           p  No         p	
Can the patient reach own feet for safe self care?	Yes           p  No         p	
Are there other factors influencing ability to safely care for own feet?	Yes           p  No         p	
Patient Status                                Criteria                                       Refer to                                    	
Low Risk Foot	Patient with diabetes and not at risk characteristics	12 Monthly Foot Assessment	
At Risk Foot	Previous ulcer; loss of sensation; ischaemia; focal callus	Podiatry
High Risk Foof Education	
High Risk Foot	Ulcer; infection; Acute Charcot's Arthropathy;	High Risk Foot Clinic	
Medical Emergency	Severe limb threatening infection; Acute vascular incident	Emergency Department	
Comments: (risk status; referral's; appointments; education, etc.)                                               	
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