S–50 THE JOURNAL OF FOOT & ANKLE SURGERY Patient: Chart # Date: Age: Diabetes duration Attending MD Height Weight BP HbA1C Type 1 Type 2 Rx - Insulin - Incretin - - Diet Oral Hypoglycemic Skin: Lesions Nails Turgor Color Temperature Texture Fissures Corns Calluses Ulcers Musculoskeletal Joint Flexibility Deformities or Sites of High Pressure Gait assessment History of: Foot Ulcer Infection Amputation Revascularization Renal Disease CAD Stroke Tobacco Alcohol Shoes Paresthesia/Tingling Numbess Burning Sharp Pain Night Pain Muscle Weakness Gait Difficulties Claudication Diabetic Foot Evaluation Mark areas of callus, ulcer or pre-ulcer, erythema, swelling, tenderness or deformity Medications: toes plantar feet to above ankle to below knee night daily occasionally wheelchair walker cane brace foot orthosis MDI Appendix 1 p1 Prior Ulceration &/or Amputation Charcot Deformity - Location __ __ 0 +1 +2 +3 0 +1 +2 +3 0 +1 +2 +3 0 +1 +2 +3 Absent Present Absent Present Absent Present Absent Present <1 1-3 >3 <1 1-3 >3 Absent Patella Achilles Right Left Deep Tendon Reflexes (+Present; - Absent) Vascular Exam Pulses: Dorsalis Pedis Posterior Tibial Elevation Pallor Dependent Rubor Capillary Filling Time Edema Neurologic Exam Right Left Pulse Exam Examiner: Date: Periodic Foot Care Extra Depth Shoes Multiple Density Insoles (MDI), Orthotics Bracing Vascular Testing: Doppler Consultation: Other: Diabetic Education Recommended Management: Left Right - Sensory Semmes-Weinstein Monofilament Ability to detect 5.07 or 10 gm Monofilament: + or - Risk Status 0 No Sensory Neuropathy, No PAD, Negative Hx of Foot Ulcer I Neuropathy (LOPS), No PAD, No Deformity II Sensory Neuropathy + PAD &/or Foot Deformity III Previous Foot Ulcer or Amputation 0 absent +1 diminished +2 normal +3 bounding DIABETIC FOOT DISORDERS VOLUME 45, NUMBER 5, SEPTEMBER/OCTOBER 2006 S–51 Appendix 1 p2 . knee night daily occasionally wheelchair walker cane brace foot orthosis MDI Appendix 1 p1 Prior Ulceration &/or Amputation Charcot Deformity - Location __ __ 0 +1 +2 +3 0 +1 +2 +3 0 +1 +2 +3 0 +1 +2 +3 Absent Present. Deformity III Previous Foot Ulcer or Amputation 0 absent +1 diminished +2 normal +3 bounding DIABETIC FOOT DISORDERS VOLUME 45, NUMBER 5, SEPTEMBER/OCTOBER 2006 S– 51 Appendix 1 p2 . +1 +2 +3 0 +1 +2 +3 Absent Present Absent Present Absent Present Absent Present < ;1 1-3 >3 < ;1 1-3 >3 Absent Patella Achilles Right Left Deep Tendon Reflexes (+Present; - Absent) Vascular