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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Resources and Services Administration

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Foot Evaluation

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 ROMR MMT L MMTL ROM

 

 

Ankle DF

 

 

 

 

Ankle PF (s,w,a)

 

 

 

 

Ankle Inversion

 

 

 

 

Ankle Eversion

 

 

 

 

Great Toe Flexion

 

 

 

 

Great Toe Extension

 

 

 

 

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)

Diagrams of left and right feet with test areas

Label: D=dryness S=swelling R=redness T=temperature M=maceration

Callus = Indicate a callus with this symbol
Pre-ulcer = Indicate a pre-ulcer with this symbol
Ulcer = Indicate an ulcer with this symbol

WAGNER PLANTAR ULCER GRADE: 0 I II III IV

Ulcer 1

 

 

 

 

 

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:

RightLeft 
  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: