This document contains a comprehensive diabetes foot exam form. It collects information on a patient's medical history including diabetes control and complications, foot examination findings, risk categorization, footwear assessment, education provided, current problems, and treatment plan. Exam findings include sensory examination, nail assessment, pedal pulses, musculoskeletal deformities, calluses, wounds, and skin and nail infections. The treatment plan and follow up duration are also documented.

1. Date: ________________
History Referred By:
Method of Control:
Insulin: □Y□N
Tab./ Oral: □Y□N
Diet: □Y□N
Control: *poor / stable / good
*Specify: ____________________
____________________
Duration of Disease: ___________
Current History:
Fill in with R=Right L=Left B=Both
Is there pain in the calf muscles when
walking that is relieved by rest?
□Y _____□N _____
Pain in the calf muscle during rest?
□Y _____ □N ______
Nails Exam:
Thick Nails □Y□N
Long Nails □Y□N
Brittle Nails □Y□N
Fungal Nails □Y□N
Ingrown Nails
Site: ______Side: _____
Presence of Complications:
□ Peripheral Neuropathy
□ Nephropathy
□ Retinopathy
□ Peripheral Vascular Disease
□ Cardiovascular Disease
Amputations:
Date: ______________________
Side: ______________________
Level: ______________________
Any Blood or Discharge on socks or
shoes?
□Y _____ □N _____
Smoking History?
□Y _____ □N _____
Amount per Day: ______
Most Recent Hemoglobin A1c result:
Value: _______% ________mol/g
Time of Day _____________
Date: ____/____/______
Infected Nails
Site: ______Side: _____
Note Muscular-skeletal
Deformities:
□ Toe deformities
□ Bunions
□ Charcot foot
□ Drop foot
□ Prominent metatarsal
heads
□ Plantar Faciitus
Past foot ulcers:
Date: ______________________
______________________
Site: ______________________
______________________
______________________
______________________
Side: ______________________
______________________
______________________
______________________
Foot dermatology Exam:.
Thin skin: □Y□N
Hairless skin: □Y□N
Cracks on the heel: □Y□N
Callus on plantar area: □Y□N
Callus on dorsum toes: □Y□N
Callus on navicular: □Y□N
Callus on malleolus: □Y□N
Pedal Pulses:
Fill in with
P = Present, A = Absent
Posterior Tibial
□Left ____ □Right ____
□Doppler _____
Dorsalis Pedis
□Left ____ □Right ____
□Doppler _____
Sensory Foot Exam. Label sensory level with a ‘+’ in the areas of the foot if the patient can feel the 5.07 (10-
gram) Semmes-Weinstein nylon monofilament and ‘-‘ if the patient cannot feel the filament.
NOTES NOTES
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Podiatry
Comprehensive
Diabetes foot exam
form

2. Right Left
Risk Categorization:
Low Risk Patient High Risk Patient
All of the following One of the following
□ Intact Protective Sensation □ Loss of protective Sensation
□ Pedal Pulse Present □ Absent of Pedal Pulses
□ No Deformities □ Foot Deformities
□ No Prior Foot Ulcer □ History of Foot Ulcer
□ No Amputations □ Prior Amputations
Measure, draw in and label the patients
conditions, using the keys on the foot
diagram below
C = Callus, U = Ulcer,
PU = Pre-Ulcer, F = Fissures,
M = Maceration, D = Dryness,
R = Redness, S = Swelling,
W = Warmth
Footwear Assessment:
Does the Patient wear appropriate shoes? □Y□N
Does the Patient need inserts? □Y□N
Should corrective footwear be prescribed? □Y□N
Will the Patient wear the appropriate footwear? □Y□N
What shoes is the Patient wearing at present?
__________________________________________________
Footwear Recommendations:
□ None □ Custom Shoes
□ Athletic Shoes □ Depth Shoes
□ Accommodative Inserts
Referred Patient To: Date:
□ Endocrinology ________
□ Gen. Surgery ______
□ Vascular Surgery ________
□ Orthopedic Surgery ________
□ Plastic Surgery ________
□ DM Foot Clinic ________
□ Wound Care Clinic ________
□ Appliance Clinic ________
□ Plaster Room for contact cast
□ Diabetic Educator ________
Education:
Has the patient had Prior foot care education? □Y□N
Can the patient demonstrate appropriate foot care? □Y□N
Does the patient require more foot care education? □Y□N
□ Nutrition Department ________
□ Home Health Care ________
□ Other Clinic / Hospital: ________
_______________________________
Current Problems: (Location, Duration, Onset, Course, Aggravating Factors, Previous Treatment).
_______________________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________
Use circles or arrows to indicate painful, injured or problem areas of the feet.
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Length of time for current problem:
______Days
______Weeks
______Months
______Years

3. Right Foot Left Foot
Medial Medial
(Continuation)
Grading Scale:
Treatment Plan:
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Current Medication for
Diabetic:
______________________
_
______________________
_
______________________
_
______________________
_
______________________
_
______________________
_
______________________
_
______________________
_
Allergies:
□ Penicillin □ Sulfa Drugs
□ Aspirin □ Codeine
□ Iodine □ Tape
□ Local Anesthetic □ Gen. Anesthetic
□ Latex
□ Other : _________________________
_________________________
Other Findings:
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
Grade 0 Grade 1 Grade 11 Grade 111
Stage A Epithelialised Superficial Tendon / Muscle Bone / Joint
Stage B Infection Infection Infection Infection
Stage C Ischemia Ischemia Ischemia Ischemia
Stage D Both Both Both Both
Podiatry
Comprehensive
Diabetes foot exam
form

4. Follow-up Durations
Follow –up Care:
Scheduled Follow–up visit: _____/_____/________
Signature: __________________ Print Name: _________________ Badge No:___________
Contact Nr: __________________ Pager Nr:____________
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□Days □Weeks □Months