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Appendix 1 (Part 1): Diabetic Foot Evaluation

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Type 1 Type 2 Rx - Insulin - Incretin - Oral Hypoglycemic - Diet Diabetes duration Attending MD Height BP Weight Date: Age: History of: HbA1C Foot Ulcer Infection Amputation Revascularization Renal Disease CAD Stroke Tobacco Alcohol Numbess Burning Paresthesia/Tingling Sharp Pain Night Pain Muscle Weakness Gait Difficulties Claudication toes plantar feet to above ankle ... to below knee night daily occasionally wheelchair walker cane brace foot orthosis MDI Shoes Skin: Turgor Color Temperature Texture Fissures Corns Calluses Ulcers Lesions Nails Musculoskeletal Mark areas of callus, ulcer or pre-ulcer, erythema, swelling, tenderness or deformity Joint Flexibility Deformities or Sites of High Pressure Gait assessment ...

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