Annual diabetes foot assessment form

1
Annual Diabetes Foot Assessment.
Date
Patient Name Address DOB Tel
Number GP Hospital or NHS number
Section 1
Type 1 / Type2 / Type 2 treated with
insulin. Glycaemic Control Good / Unstable /
Poor. Latest HBA1c if known ....
Date.. Year Diabetes Diagnosed
Medication History of Diabetes Eye Problems
/ Diabetes Kidney Problems M I/ Stroke Smoker
Yes / No Anticoagulant Therapy Yes / No

Absent Dorsalis Pedis
and Posterior Tibial Pulse. If one foot pulse
palpable then PVD unlikely Less than
10/10 Monofilaments Reactions. Previous history
of ulcer or amputation
Section 2 Please note comments in italics
LEFT
RIGHT
RIGHT
LEFT
Atrophy of skin/ friable tissue Foot deformity
(Clawing Toes/ Bunion/ High Arched Foot/ Charcot
) Unsuitable footwear If no other risk factors
offer education advice. Refer to Podiatry if
foot pathology present. Presence of callus or
abnormal nails Poor vision restricting ability
to care for feet.

• Please refer patient to Dept Foot Health, Arundel
  Building,
• Brighton General Hospital if any of section 2
  boxes are ticked.

Section 3
At Risk Category (please tick)
Referral made by
Name Base Designation

• Low current risk normal sensation and
  palpable pulses
• At risk neuropathy, absent pulses or other
  risk factor
• High risk neuropathy or absent pulses plus
  deformity or skin changes
• or previous ulcer.
• Foot care emergencies new ulceration,
  swelling or discolouration.

Review Date. / / If required
please refer Diabetes Foot Ulcers to Podiatry,
Diabetes Centre, RSCH.
Comments or reason for referral