How to Do a Level-One Foot Screening

Printer-Friendly Level-One Foot Screening Form (PDF-5.4 MB)

Diabetic Neuropathy is a degenerative disease of the peripheral nerves and a common complication of diabetes. Autonomic, sensory and motor functions may be affected individually or in combination with varying degrees of severity. This nerve damage can create conditions in the foot that produce secondary problems such as deformity and foot ulceration, which may lead to amputation. It is our hope to minimize or eliminate the devastating effects of peripheral neuropathy through careful monitoring of the feet using a foot screen, patient education and appropriate referral to a foot care specialist when needed.

Three levels of screening exist for the diabetic foot depending on the level of expertise of the individual performing the evaluation.

The Level One Leap Foot Screen may be completed by a nurse or health-care professional who is familiar with the foot and able to perform basic strength and sensory testing.

Diabetes Foot Screen
Name (Last, First, MI) __________________________________ Date:______
Fill in the following blanks with a "Y" or "N" to indicate findings in the right or left foot.
 
R
L
Is there a history of a foot ulcer? _________ _________
Is there a foot ulcer now? _________ _________
Is there a claw toe deformity? _________ _________
Is there swelling or an abnormal foot shape? _________ _________
Is there elevated skin temperature? _________ _________
Is there limited ankle dorsiflexion _________ _________
Are the toenails long, thick or ingrown? _________ _________
Is there heavy callous build-up? _________ _________
Is there foot or ankle muscle weakness? _________ _________
Is there an absent pedal pulse? _________ _________
Can the patient see the bottom of their feet? _________ _________
Are the shoes appropriate in style and fit? _________ _________
Note the level of sensation in the circles:
+ = Can feel the 5.07 filament - = Can't feel the 5.07 filament
Left
Foot Screen Test Sites
Right

Skin Conditions on the Foot or Between the Toes
Draw in: Callous, Pre-ulcer, Ulcer (note length and width in cm)
Label with: R - redness, M - maceration, D - dryness, T - Tinea

Risk Category

____ 0 No loss of protective sensation.
____ 1 Loss of protective sensation
____ 2 Loss of protective sensation with either high pressure (callous/deformity), or poor circulation.
____ 3 History of plantar ulceration, neuropathic fracture (Charcot foot) or amputation

Performed by ________________________

______________________________

 

Date Last Reviewed:  April 2017


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