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Get and Sign Diabetic Foot Exam Documentation 2006-2022 Form
Right
Abnormal shape?
No / Right
Charcot foot?
No / Right
Toe deformity?
No / Right
Thick or ingrown toenails? No / Right
Callus build-up?
No / Right
Edema?
No / Right
Elevated skin temp?
No / Right
Decreased circulation?
No / Right
Loss of sensation?
No / Right
Muscle weakness?
No / Right
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/
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Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
Left
PERIPHERAL ARTERY DISEASE (PAD) SCREEN
History of claudication?
No
Yes
Pedal pulses...
Show details
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