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    DM DFU Foot Assessment Form Draft

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    ikhlasliving
    This diabetic foot assessment form collects information on a patient's risk factors, symptoms, and examination findings. It assesses neurological, vascular, and musculoskeletal components of both feet. Based on the results, the patient is stratified into a risk category for foot ulceration and a management plan is outlined, which may include education, referrals to specialists, and a follow up schedule.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    DM DFU Foot Assessment Form Draft

    Uploaded by

    ikhlasliving
    76 views3 pages
    This diabetic foot assessment form collects information on a patient's risk factors, symptoms, and examination findings. It assesses neurological, vascular, and musculoskeletal components of both feet. Based on the results, the patient is stratified into a risk category for foot ulceration and a management plan is outlined, which may include education, referrals to specialists, and a follow up schedule.

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    DM DFU Foot Assessment Form draft

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    This diabetic foot assessment form collects information on a patient's risk factors, symptoms, and examination findings. It assesses neurological, vascular, and musculoskeletal components of both feet. Based on the results, the patient is stratified into a risk category for foot ulceration and a management plan is outlined, which may include education, referrals to specialists, and a follow up schedule.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    76 views3 pages

    DM DFU Foot Assessment Form Draft

    Uploaded by

    ikhlasliving
    This diabetic foot assessment form collects information on a patient's risk factors, symptoms, and examination findings. It assesses neurological, vascular, and musculoskeletal components of both feet. Based on the results, the patient is stratified into a risk category for foot ulceration and a management plan is outlined, which may include education, referrals to specialists, and a follow up schedule.

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    © All Rights Reserved
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    You are on page 1of 3

    DIABETIC FOOT ASSESSMENT FORM

    KLINIK KESIHATAN:_________________________ DATE OF ASSESSMENT: ________

    PERSONAL DATA
    NAME:___________________________________ SMOKER: YES / NO
    IDENTIFICATION CARD NUMBER: ________________________________
    RISK FACTORS: □ Peripheral Arterial Disease □ Previous Diabetic Foot Ulcer
    □ End Stage Renal Failure □ Previous amputation

    Kindly (√) at the appropriate box if symptoms / abnormal findings are present

    CURRENT SYMPTOMS Left Right Description


    Paraesthesia (Pin & Needles) (_____) (_____)

    T
    Intermittent Claudication (_____) (_____)
    Resting Pain (_____) (_____)
    Active foot ulcer (_____) (_____)
    Prosthesis AF (_____) (_____)

    Type of footwear Indoor Outdoor

    GENERAL EXAMINATION Left Right Description


    Skin changes or redness (_____) (_____)
    Foot oedema / swelling (_____) (_____)
    Corns / Callosities (_____) (_____)
    Ulcers / Open wounds (_____) (_____)
    Bunions (_____) (_____)
    Lesser toe deformities (_____) (_____)
    R
    Charcot Joints (_____) (_____)

    Please draw/specify any abnormalities identified.


    LEFT RIGHT
    D

    Page 1
    NEUROLOGICAL EXAMINATION Left Right Description
    Muscle wasting (_____) (_____)
    Loss of proprioception (_____) (_____)
    Loss of vibration perception (_____) (_____)

    Semmes-Weinstein 10gram Monofilament Test


    Left Right
    1
    2
    3

    6 5 4
    10

    8 7

    T
    /10 9 /10
    (intact) (intact)

    VASCULAR EXAMINATION
    Atrophic skin changes
    Dystrophic nails
    AF
    Remark: (√) if intact, (×) if absent

    Left
    (_____)
    (_____)
    Right Description
    (_____)
    (_____)
    Absence of hair (_____) (_____)
    Abnormal temperature gradient (_____) (_____)
    Capillary refill >3s (_____) (_____)

    PALPABLE PULSES Left Right


    R
    Dorsalis Pedis Artery (DPA) (_____) (_____)
    Posterior Tibial Artery (PTA) (_____) (_____)
    Popliteal Artery (PA) (_____) (_____)
    Femoral Artery (FA) (_____) (_____)
    Remark as either: ++ (Normal), + (Weak), - (Absent) or not done.
    D

    ANKLE-BRACHIAL INDEX (ABI) Left Right


    Brachial SBP (mmHg) (_____) (_____) Normal ABI ratio: 0.9 - 1.3
    Dorsalis Pedis SBP (mmHg) (_____) (_____) ABI ratio < 0.9: Likely PAD
    Posterial Tibial SBP (mmHg) (_____) (_____)
    ABI (Ankle SBP / Brachial SBP)* (_____) (_____)
    Note: SBP: Systolic Blood Pressure
    *For ankle SBP: use either DPA or PTA whichever is higher

    Page 2
    Risk Stratification
    Category Ulcer Risk Characteristics Screening Frequency
    □0 Very Low No LOPS AND no signs of PAD Once a year
    □1 Low LOPS OR PAD Once every 6-12 months
    □2 Moderate LOPS + PAD or Once every 3-6 months
    LOPS + foot deformity or PAD + foot deformity
    □3 High LOPS or PAD + one of the following Once every 1-3 months
    - a history of foot ulcer
    - a lower extremity amputation (minor or major)
    - end stage renal failure
    Note: Loss of Protective Sensation (LOPS): Loss of either vibration perception and/or pressure
    perception (abnormal monofilament test). Peripheral Arterial Disease (PAD): abnormal ABI / Weak
    or absent pulses +/- history of intermittent claudication (if ABI unavailable)

    T
    Management Plan
    Foot care education
    □ Foot hygiene □ Footwear advice (proper footwear, avoid barefoot)
    □ Nail care □ Daily foot check (for any skin changes/infection/new ulcer)
    □ Emollient use

    Referral
    □ MO
    □ FMS
    AF □ Advice to avoid massage/soaking/self-treatment
    □ Wound care advice (if needed)

    □ Wound Care Team


    □ Vascular
    □ Occupational Therapy □ Orthopedic
    □ Physiotherapy □ Endocrine
    □ Diabetic Educator □ Others: ________________________________

    Follow up plan
    R
    □ 1-3 monthly
    □ 3-6 monthly
    □ 6-12 monthly
    □ Yearly
    □ Next DFU screening due: __________________
    D

    Name of Assessor: _____________________


    Cop & Sign:

    Page 3

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