Foot Evaluation
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 |
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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) |
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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
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
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| Hammer/Claw Toe |
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| Bunion/Bony Prominence |
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| Drop Foot |
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| Charcot Foot |
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| Hallux Limitus |
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| Rear/Forefoot Varus |
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| PF 1 st ray/Forefoot Valgus |
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| Equinus/Calcaneus |
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| Pes Planus/Cavus |
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| Partial Foot Amputation/Absorption |
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| Other: |
VASCULAR:
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Pulses Absent |
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Capillary Refill > 3 seconds |
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Ankle/Brachial Index |
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TCP02 |
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FOOT RISK CATEGORY:
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0 (0) |
No protective sensory loss |
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1 (1) |
Loss of protective sensation (no deformity or plantar ulcer history) |
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2 (2) |
Loss of protective sensation plus deformity (no plantar ulcer history) |
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3 (3) |
History of plantar ulcer |
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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: |
