A diabetes foot exam is an important part of managing your diabetes. This form can help you keep track of the results of your foot exams. You can use this form to discuss any concerns or problems you have with your doctor. Completed by: ____________________________ Date: ___________________________ Time: _____________________ Feet were inspected for color, temperature, pulses and sensation. Looked for redness, blisters, calluses, cuts and nails abnormalities. Check WNL (within normal limits) as appropriate. No Concerns/Issues detected today. Comments:____________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Foot Exam Form PDF Version
Question | Answer |
---|---|
Form Name | Diabetes Foot Exam Form |
Form Length | 1 pages |
Fillable? | Yes |
Fillable fields | 67 |
Avg. time to fill out | 13 min 43 sec |
Other names | diabetic foot exam form, diabetes exam form printable, annual diabetes foot, diabetes foot form |
ANNUAL COMPREHENSIVE DIABETES FOOT EXAM FORM
TOOLS
5. Vibration Perception with
Check appropriate box. ! Normal (+)
! Abnormal
! Socks
WisconsinDiabetesMellitusEssentialCareGuidelines•2012
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