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NDEP | National Diabetes Education Program
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Following the Foot Screening Instructions, Print this page and complete the form by hand
Name:
Date:
ID :
I Medical History
Check all that apply _____ _____ _____ _____ _____ Peripheral Neuropathy Nephropathy Retinopathy Peripheral Vascular Disease Cardiovascular Disease
For Sections II III, fill in the blanks with an R, L, or B for positive findings on the right, left, or both feet
II Current History
1 Any change in the foot since the last evaluation? _____ Yes ____________ _____ No 2 Current ulcer or history of a foot ulcer? _____ Yes ____________ _____ No 3 Is there pain in the calf muscles when walking that is relieved by rest? _____ Yes ____________ _____ No
III Foot Exam
http://wwwndepnihgov/resources/feet/screenfohtm
2/23/2005
NDEP | National Diabetes Education Program
1 Are the nails thick, too long, ingrown, infected with fungal disease? _____ Yes ____________ _____ No 2 Note foot deformities _____ Toe deformities _____ Bunions Hallus Valgus _____ Charcot foot _____ Foot drop _____ Prominent Metatarsal Heads _____ Amputation Specify date, side and level ________________________ 3 Pedal Pulses Fill in the
blanks with a P or an A to indicate present or absent Posterior tibial: _____ Left _____ Right Dorsalis pedis: _____ Left _____ Right
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4 Skin Condition Measure, draw in and label the patients skin condition, using the key and the foot diagram below C Callus U Ulcer R Redness W Warmth M Maceration PU Pre -ulcerative lesion F Fissure S Swelling D Dryness
IV Sensory Foot Exam
Label sensory level with a in the five circled areas of the foot if the patient can feel the 507 SemmesWeinstein 10-gram nylon filament and - if the patient cannot feel the filament To obtain a monofilament, see the NDEP Order Form
V Risk Categorization
Check appropriate item
http://wwwndepnihgov/resources/feet/screenfohtm
2/23/2005
NDEP | National Diabetes Education Program
_____ Low Risk Patient All of the following: Intact protective sensation Pedal pulses present No severe defor 
mity No prior foot ulcer No amputation _____ High Risk Patient One or more of the following: Loss of protective sensation Absent pedal pulses Severe foot deformity History of foot ulcer Prior amputation
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VI Footwear Assessment
Fill in the blanks Does the patient wear appropriate shoes? _____ Yes
_____ No Does the patient need inserts? _____ Yes _____ No Should therapeutic footwear be prescribed? _____ Yes _____ No
VII Education
Fill in the blanks Has the patient had prior foot care education? _____ Yes _____ No Can the patient demonstrate appropriate self-care? _____ Yes _____ No
VIII Management Plan
Check all that apply _____ Provide patient education for preventive foot care Date: ________________________ Diagnostic studies: _____ Vascular laboratory _____ Other: ________________________ Footwear recommendations: _____ None _____ Athletic shoes _____ Accommodative inserts _____ Custom shoes _____ Depth shoes Refer to: _____ Primary Care Provider _____ Diabetes Educator _____ Orthopedic Foot Surgeon _____ RN Foot Specialist _____ Orthotist _____ Podiatrist _____ Pedorthist _____ Endocrinologist _____ Rehab Specialist _____ Vascular Surgeon
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2/23/2005
NDEP | National Diabetes Education Program
_____ Other: ________________________ _____ Schedule follow-up visit
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Date:____________ Provider Signature:_______________________________
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National Diabetes Education Program NDEP
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http://wwwndepnihgov/resources/feet/screenfohtm
2/23/2005
Source:diabetesmonitor.com
