M Maddocks Inc
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Podiatric Diabetic Foot Screening

"*" indicates required fields

Name
DD slash MM slash YYYY
Start Time
:
End Time
:
Podiatrist
Which Appt?

HISTORY

Type of Diabetes

Diabetic Medication
Other Conditions
Other Medications
48 mmol/mol (6.5%) or below
Previous Foot Ulcer
Smoker
Current Physical Activity / Exercise
Does the patient meet the WHO exercise guidelines?
Description: 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; also muscle-strengthening activities involving all major muscle groups on 2 or more days a week.

SKIN / DERMATOLOGY

Ingrown Toenail/s - RIGHT

Ingrown Toenail/s - LEFT

Thick Toenail/s - RIGHT

Thick Toenail/s - LEFT

Dry Skin - RIGHT

Dry Skin - LEFT

Corns / Callus - RIGHT

Corns / Callus - LEFT

Heel Fissures - RIGHT

Heel Fissures - LEFT

Fungal Infection: Nails - RIGHT

Fungal Infection: Nails - LEFT

Fungal Infection: Skin - RIGHT

Fungal Infection: Skin - LEFT

Bacterial Infection - RIGHT

Bacterial Infection - LEFT

Ulcer - RIGHT

Ulcer - LEFT

Gangrene - RIGHT

Gangrene - LEFT

Other - RIGHT

Other - LEFT

VASCULAR ASSESSMENT

ABPI description: > 1.4 calcification 1 - 1.3 Normal 0.9 - 0.99 borderline (start PAD) 0.8 - 0.89 mild blockage (PAD) 0.5 - 0.79 (intermittent claud) < 0.5 (resting pain)
Dorsalis Pedis Pulse - RIGHT
Dorsalis Pedis Pulse - LEFT
Anterior Tibial Pulse - RIGHT
Anterior Tibial Pulse - LEFT
Posterior Tibial Pulse - RIGHT
Posterior Tibial Pulse - LEFT
Capillary Refill Time (s) - RIGHT
Capillary Refill Time (s) - LEFT
Presence of Hair - RIGHT
Presence of Hair - LEFT
Colour - RIGHT

Colour - LEFT

Temperature - RIGHT

Temperature - LEFT

Exercise Induced Calf Pain / Intermittent Claudication - RIGHT

Exercise Induced Calf Pain / Intermittent Claudication - LEFT

Cramps - RIGHT

Cramps - LEFT

Burning Sensations - RIGHT

Burning Sensations - LEFT

NEUROLOGICAL ASSESSMENT

10 g Monofilament - RIGHT
10 g Monofilament - LEFT
Vibration - RIGHT
128 Hz tuning fork
Vibration - LEFT
128 Hz tuning fork
2 Point Discrimination - RIGHT
2 Point Discrimination - LEFT
Big Toe Proprioception - RIGHT
Big Toe Proprioception - LEFT
Light Touch - RIGHT
Light Touch - LEFT
Temperature Discrimination - RIGHT
Temperature Discrimination - LEFT
Sharp / Blunt Discrimination - RIGHT
Sharp / Blunt Discrimination - LEFT
Babinsky Reflex - RIGHT
Babinsky Reflex - LEFT
Achilles / Ankle Reflex - RIGHT
Achilles / Ankle Reflex - LEFT
Patella Reflex - RIGHT
Patella Reflex - LEFT
Single Leg Balance - RIGHT
Single Leg Balance - LEFT

ORTHOPEADIC / MUSCULOSKELETAL

Ankle Dorsiflexion - RIGHT
Ankle Dorsiflexion - LEFT
Ankle Plantarflexion - RIGHT
Ankle Plantarflexion - LEFT
Subtalar Joint Inversion - RIGHT
Subtalar Joint Inversion - LEFT
Subtalar Joint Eversion - RIGHT
Subtalar Joint Eversion - LEFT
Midtarsal Joint - RIGHT
Midtarsal Joint - LEFT
Metatarsophalangeal Joints - RIGHT
Metatarsophalangeal Joints - LEFT
Interphalangeal Joints - RIGHT
Interphalangeal Joints - LEFT
Lesser Toe Deformities - RIGHT

Lesser Toe Deformities - LEFT

Other Bony Prominences - RIGHT

Other Bony Prominences - LEFT

Charcot Neuroarthropathy - RIGHT

Charcot Neuroarthropathy - LEFT

Lower Leg Amputations - RIGHT

Lower Leg Amputations - LEFT

PRESSURE PLATE SCREENING

Static only
High Presssure Areas - RIGHT
High Presssure Areas - LEFT
Drop files here or
Max. file size: 32 MB, Max. files: 10.

    FOOTWEAR

    Appropriate

    OTHER

    Self-Care Practice

    COMMENTS

    Podiatric Diagnoses (to be added to main Diabetic code)
    Foot Ulcer Risk Category
    Referral to
    Next Podiatric Diabetic Foot Screening
    To Come Back - For Podiatric Care*
    Email report to:
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