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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your name, date, and age at onset of diabetes at the top of the form.
- In the Medical History section, check all applicable conditions such as Peripheral Neuropathy or Retinopathy. Be sure to include your most recent hemoglobin A1c results.
- Proceed to Current History and answer questions regarding any changes in your feet since the last evaluation, current ulcers, or calf pain.
- In the Foot Exam section, assess your foot's sensory level using the provided monofilament test and note any deformities or pedal pulses.
- Complete the Risk Categorization by checking if you are a low-risk or high-risk patient based on your responses.
- Finally, review the Management Plan and Education sections to ensure all necessary information is included before signing.
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