LSUHSC Diabetes Foot Program: Outcome Form. Patient: _Date: How many times have you been hospitalized for a foot or toe problem? …
LSUHSC Diabetes Foot Program: Outcome Form
Patient: ________________________________________ Date:
___/___/___
Phone: _______________ Chart ____________ Date First Visit:
___/___/___
Estimate in the past 12 months:
How many days you had an open sore ulcer on your foot or toe?
__________
How many different ulcers? __________
How many times have you been hospitalized for a foot or toe problem?
__________
How many days you spent in the hospital for a foot or toe problem?
__________
How many times you went to the Emergency Room for foot/toe problem?
__________
How many times you took antibiotics for a foot or toe problem?
__________
How many foot fractures did you have in the past 12 months?
__________
How many operations have you had on your foot or toe?
__________
How many of each:
Surgical debridement? __________
Toe amputation? __________
Ray amputation? __________
Mid-foot amputation? __________
Below knee amputation?
__________
Above knee amputation? __________
Other foot operations? _________________________________________
Do you work? Y / N
How many days you missed work for a foot or toe problem? __________
Estimate what year you were diagnosed with Diabetes
__________
Is there a current active Charcot? Y / N
Is there an open ulcer at this visit? Y / N
Is the patient on dialysis? Y / N
__________________________
Rev 07/02/01 LSUHSC-DFP
Source:mc.uky.edu
