Foot Screening Form PDF Details

diabetes, foot care is extremely important. Many people with diabetes don't realize that they are walking around with high blood sugar levels and this can lead to some serious health complications down the road if left untreated. By taking a few minutes out of your day to complete a foot screening form, you can ensure that you are taking appropriate steps to maintain healthy feet. If you have any concerns or questions about your feet, be sure to consult with your doctor or podiatrist. For more information on foot care for people withdiabetes, foot care is extremely important. Many people with diabetes don't realize that they are walking around with high blood sugar levels and this can lead to some serious health complications down the road if left untreated. By taking a few minutes out of your day to complete a foot screening form, you can ensure that you are taking appropriate steps to maintain healthy feet. If you have any concerns or questions about your feet, be sure to consult

QuestionAnswer
Form NameFoot Screening Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswhat to chart on diabetic feet assessment, podiatry foot screening template, comprehensive diabetic foot exam forms, diabetic foot check patient logs

Form Preview Example

Podiatry Foot Screening Form

Name:

 

 

 

DOB:

 

 

 

Address:

City:

 

State:

 

 

 

 

 

 

 

 

 

Zip Code:

 

 

 

Phone Number:

 

 

Primary Care Physician:

 

 

 

Medications/Vitamins/Minerals:

 

 

 

 

 

 

 

Have you ever seen a Podiatrist?

 

Yes ______

 

 

No ______

 

 

If yes, who did you see:

 

 

 

 

 

 

 

If yes, was your last visit in 2010?

Yes ______

 

 

No ______

Do you have Diabetes?

 

 

Yes ______

 

 

No ______

Have you been diagnosed with PVD (Peripheral Vascular Disease)?

Yes ______

 

 

No ______

Do you have pain in your feet or ankles at rest or with exercise?

Yes ______

 

 

No ______

Do you have pain in your feet or ankles with sports activities?

Yes ______

 

 

No ______

Do you wear orthodics or special shoes?

 

 

Yes ______

 

 

No ______

INSPECTION

 

 

 

Right

 

Bunion

YES ______

NO ______

Callus

YES ______

NO ______

Hammertoe

YES ______

NO ______

Skin Exam

NORMAL_____ XIRROSIS_____

TINEA_____

Pulses: Dorsalis Pedis

NORMAL____ DIMINISHED ___

ABSENT___

Pulses: Tibialis Posterior

NORMAL____ DIMINISHED ___

ABSENT___

Neurologic Exam

NORMAL____ DIMINISHED ___

 

Left

 

YES ______

NO ______

YES ______

NO ______

YES ______

NO ______

NORMAL_____ XIRROSIS_____

TINEA____

NORMAL____ DIMINISHED ___

ABSENT___

NORMAL____ DIMINISHED ___

ABSENT___

NORMAL____ DIMINISHED ___

 

NEUROLOGICAL EXAM

RISK CATEGORY

 

 

 

______

No problems identified on exam

 

______

Refer to Podiatry

 

 

 

Completed by:

 

Date:

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The way to complete foot screening form stage 1

2. After the last part is complete, you have to include the required particulars in Skin Exam, NormalXirrosis, Tinea NormalXirrosis, Tinea, Pulses Dorsalis Pedis, Normal Diminished Absent Normal, Pulses Tibialis Posterior, Normal Diminished Absent Normal, Neurologic Exam, Normal Diminished, Normal Diminished, NEUROLOGICAL EXAM, RISK CATEGORY, No problems identified on exam, and Completed by in order to move on to the next step.

How to fill in foot screening form stage 2

As for Skin Exam and NEUROLOGICAL EXAM, be certain that you take another look here. The two of these are surely the key ones in this PDF.

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