Basic Foot Assessment Checklist
(All people with diabetes need to have their feet assessed with these 7 simple steps every 6 months or more often if problems are identified)	

1.  Ask the patient 	
Neuropathic Symptoms	q  Yes   q  No	
Rest Pain	q  Yes   q  No	
Intermittent claudication	q  Yes   q  No	
Previous foot ulcer	q  Yes   q  No	
Amputation	q  Yes   q  No	
Specify SITE & Date	Site:                                                             Date: <TodaysDate>	
2.  Look at Both Feet 	
Infection	q  Yes   q  No	
Ulceration	q  Yes   q  No	
Calluses or corns	q  Yes   q  No	
Skin Breaks	q  Yes   q  No	
Nail Disorders	q  Yes   q  No	
3.  Check foot pulses 	
Left	
Right	

Dorsalis pedis	
q  Yes	
 q  No	
q  Yes	
 q  No	

Posterior tibial	
q  Yes	
 q  No	
q  Yes	
 q  No	

4.  Test for neuropathy - *Detected at sites marked 1,2 & 3	
Monofilament

            1. 

            2.

            3.	
Left

q  Yes

q  Yes

q  Yes	
Right

q  No

q  No

q  No	

	
5. Assess footwear 	
Style	
q  Good   q  Poor	

Condition	
q  Good   q  Poor	

Fit	
q  Good   q  Poor	

6.  Assess education needs 	
Does the patient understand the effects of diabetes on foot health?	  q  Yes   q  No	
Can the patient identify appropriate foot care practices?	  q  Yes   q  No	
Are the patient's feet adequately cared for?	  q  Yes   q  No	
7. Assess self care capacity 	
Does the patient have impaired vision?	  q  Yes   q  No	
Can the patient reach own feet for safe self care?	  q  Yes   q  No	
Are there other factors influencing ability to safely care for own feet?	  q  Yes   q  No	

ACTION PLAN - following Basic Foot Assessment	

Date of Referral:   <TodaysDate>
Patients Name:  <PtFullName>	Service Provider:  <DrDetails>	
   
Is the foot high risk?	  q  Yes   q  No (Re-check in 6 months)	
If Yes, Why?	  q History of previous foot ulceration, problems or amputation	
	  q Peripheral neuropathy	
	  q Peripheral vascular disease	
	  q Foot deformity	
	  q Other - Please specify..............................................................................	

Action
Record details of personnel referred to.  Where resources are unavailable, indicate and describe alternative care provision.	

1.  Ulceration or significant infection 
- Referred to multidiciplinary team: 		

2.  'High Risk' foot 
- Refered to podiatrist and/or multidisciplinary team:		
- Refered for medical assessment at least every 6 months and foot examination every 3 months: 		

3.  Active Foot Problem
- Referredd to podiatrist: 		

4.  Symptomatic peripheral vascular disease 
- Referred to vascular surgeon: 		
- Involving endocrinologist/physician		

5.  Symptomatic peripheral neuropathy 
- Referred to endocrinologist		
	
6.  Foot deformity or abnormality 
- Referred to podiatrist		

7.  Inadequate knowledge or foot care practices 
- Referred to: 		
- or education provided	  q Yes	

The patient's General Practitioner or Local Medical Officer will usually be responsible for coordinating the patient's care and should be informed of referrals, interventions and progress.