Printer-friendly Foot Evaluation form
Name: ___________________________________________________
Age: ______ ID# ________________________ Date: ____/____/_____
Diagnosis: LL ____ BL ____ TL ____ Diabetes ____ PVD ____ Venous Insuff. ____ Other
Medical Hx: Foot Ulcer: Y ___ N ___ Location: __________________________________________
Surgery: Y ___ N ___ Describe: _____________________________________________________
Complaints / Changes in foot in last year:
Employed: Y ___ N ___ Job description: ________________________________
Current Residence: _________________________________
| R ROM | R MMT | L MMT | L ROM | |
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Ankle DF |
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Ankle PF (s,w,a) |
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Ankle Inversion |
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Ankle Eversion |
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Great Toe Flexion |
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Great Toe Extension |
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Intrinsics (s,w,a) |
PLANTAR SENSATION: Sensory Level
1 = 1g (4.17) Normal sensation
2 = 10g (5.07) Protective sensation
3 = 75g (6.10) Loss of protective sensation
4 = No perception of 75g (insensate)
Label: D=dryness S=swelling R=redness T=temperature M=maceration
Callus = 
Pre-ulcer = 
Ulcer = 
WAGNER PLANTAR ULCER GRADE: 0 I II III IV
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Ulcer 1 |
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Ulcer 2 |
NERVE PALPATION:
Common Peroneal at Fibular head: Enlarged__ Tender__ (Right, Left foot)
Posterior Tibial at Med. Malleolus: Enlarged__ Tender__ (Right, Left foot)
Sural Sensory at Lat. Lower Leg: Enlarged__ Tender__ (Right, Left foot)
VISION
Able to identify foot mark (Y/N)
MOBILITY
Independent
Homebound
Independent w/ assist. device
Non-ambulatory
Requires SBA
DEFORMITIES:
| Right | Left | |
| Hammer/Claw Toe | ||
| Bunion/Bony Prominence | ||
| Drop Foot | ||
| Charcot Foot | ||
| Hallux Limitus | ||
| Rear/Forefoot Varus | ||
| PF 1 st ray/Forefoot Valgus | ||
| Equinus/Calcaneus | ||
| Pes Planus/Cavus | ||
| Partial Foot Amputation/Absorption | ||
| Other: |
VASCULAR:
| Pulses Absent | ||
| Capillary Refill > 3 seconds | ||
| Ankle/Brachial Index | ||
| TCP02 | ||
FOOT RISK CATEGORY:
| 0 (0) | No protective sensory loss | ||
| 1 (1) | Loss of protective sensation (no deformity or plantar ulcer history) | ||
| 2 (2) | Loss of protective sensation plus deformity (no plantar ulcer history) | ||
| 3 (3) | History of plantar ulcer | ||
PLAN:
(Check all that apply)
Patient Education: skin care, inspection, footwear
Posterior Walking Splint/Total Contact Cast
Wound Care
Sandals: quickie__ semi-rigid__ rigid__
Orthotics: moldable__ non-moldable__
Therapeutic Exercise/ROM
Referrals:
Other:
Clinician:
