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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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Your provider will check: The skin of your feet to look for dryness, cracking, calluses, blisters, ulcers, and other damage or abnormal areas. Your toenails for cracks and fungal infection. The temperature of your feet to see if they are the same.
What is checked in a diabetes foot assessment?
examining your foot shape and footwear to see whether you may be at risk of rubbing or pressure. checking your skin for changes in colour and looking for ulcers, sores, areas of hard skin and any signs of inflammation or infection. testing the feeling in your feet to see how well the nerves are working.
What are the 5 principles of foot care?
Basic care for healthy feet Wash your feet every day and dry them completely. Clip your toenails short and keep them clean. Change your socks at least once a day. Check your feet regularly for cuts, sores, swelling, dryness, and infected toenails and apply treatment as needed.
How to score a diabetic foot exam?
Skin. 0 = intact and healthy. 1 = dry with fungus or light callus. 2 = heavy callus build up. 3 = open ulceration or history of previous ulcer. Temperature Cold. 0 = foot warm. 1 = foot is cold. Temperature Hot. Sensation Monofilament Testing. 0 = 10 sites detected. 2 = 7 to 9 sites detected. 4 = 0 to 6 sites detected.
What are the ADA guidelines for diabetic foot exams?
All patients with diabetes must have their feet evaluated at least at yearly intervals for the presence of the predisposing factors for ulceration and amputation (neuropathy, vascular disease, and deformities).
1. Record the number of sites felt out of the total number of sites tested as per above. 2. If the monofilament was not felt in a particular site on the foot, this loss of protective sensation finding is to documented and communicated to the clients care team.
What equipment is needed for a diabetic foot exam?
Includes polypropylene case with either a bi-directional (MD2) or non-directional (D900) Dopplex Doppler and 8 Mhz probe, sphygmomanometer, arm/ankle, large and small toe cuff, 10g monofilament, educational video, ABPI and TBPI guide, tube of gel and headphones.
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