Diabetes Foot Exam Form - wellnesslifesystemscom 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name, date, and age at onset of diabetes at the top of the form.
3. 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.
4. Proceed to Current History and answer questions regarding any changes in your feet since the last evaluation, current ulcers, or calf pain.
5. In the Foot Exam section, assess your foot's sensory level using the provided monofilament test and note any deformities or pedal pulses.
6. Complete the Risk Categorization by checking if you are a low-risk or high-risk patient based on your responses.
7. Finally, review the Management Plan and Education sections to ensure all necessary information is included before signing.

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