Client Name

DOB

BASIC LOWER LIMB ASSESSMENT PHN

FLOW SHEET Or addressograph / label
Parameter Right Lower Limb Left Lower Limb Parameter Right Lower Limb Left Lower Limb
Missing Limbs ☐☐ Leg above knee ☐☐ Leg above knee Range of Motion Knee (Active): Knee (Active):
or Digits ☐☐ Leg below knee ☐☐ Leg below knee  ☐ Normal  ☐ Decreased  ☐ Normal  ☐ Decreased
☐☐ Foot partial ☐☐ Foot partial Knee (Passive): Knee (Passive):
☐☐ Foot all ☐☐ Foot all  ☐ Normal  ☐ Decreased  ☐ Normal  ☐ Decreased
☐☐ Great toe ☐☐ Great toe Ankle (Active): Ankle (Active):
☐☐ Second toe ☐☐ Second toe  ☐ Normal  ☐ Decreased  ☐ Normal  ☐ Decreased
☐☐ Third toe ☐☐ Third toe Ankle (Passive): Ankle (Passive):
☐☐ Fourth toe ☐☐ Fourth toe  ☐ Normal  ☐ Decreased  ☐ Normal  ☐ Decreased
☐☐ Fifth toe ☐☐ Fifth toe Great Toe (Active): Great Toe (Active):
☐☐ No amputations ☐☐ No amputations  ☐ Normal  ☐ Decreased  ☐ Normal  ☐ Decreased
Skin Colour Lower Leg: Lower Leg: Great Toe (Passive): Great Toe (Passive):
☐☐ Pale ☐☐ Pale  ☐ Normal  ☐ Decreased  ☐ Normal  ☐ Decreased
☐☐ Flesh tone ☐☐ Flesh tone Edema Location ☐☐ Foot ☐☐ Foot
☐☐ Red ☐☐ Red ☐☐ Up to ankle ☐☐ Up to ankle
☐☐ Bluish/Purple ☐☐ Bluish/Purple ☐☐ Up to midcalf ☐☐ Up to midcalf
☐☐ Black ☐☐ Black ☐☐ Up to knee ☐☐ Up to knee
Foot: Foot: ☐☐ Up to groin ☐☐ Up to groin
☐☐ Pale ☐☐ Pale ☐☐ No visible edema ☐☐ No visible edema
☐☐ Flesh tone ☐☐ Flesh tone Severity ☐☐ +1 Trace 2 mm pitting ☐☐ +1 Trace 2 mm pitting
☐☐ Red ☐☐ Red ☐☐ +2 Moderate 4 mm ☐☐ +2 Moderate 4 mm
☐☐ Bluish/Purple ☐☐ Bluish/Purple pitting pitting
☐☐ Black ☐☐ Black ☐☐ +3 Deep 6 mm pitting ☐☐ +3 Deep 6 mm pitting
Toes: Toes: ☐☐ +4 Very deep 8 mm ☐☐ +4 Very deep 8 mm
☐☐ Pale ☐☐ Pale pitting pitting
☐☐ Flesh tone ☐☐ Flesh tone ☐☐ Non-pitting ☐☐ Non-pitting
☐☐ Red ☐☐ Red ☐☐ None noted ☐☐ None noted
☐☐ Bluish/Purple ☐☐ Bluish/Purple
Sleep Position
☐☐ Black ☐☐ Black
Skin Warmth Lower Leg: Lower Leg: Circumference 10 cm up from heel: cm 10 cm up from heel: cm
☐☐ Hot ☐☐ Hot Measurements
30 cm up from heel: cm 30 cm up from heel: cm
☐☐ Warm ☐☐ Warm
☐☐ Cool ☐☐ Cool Skin ☐☐ Dry/flaky ☐☐ Dry/flaky
☐☐ Cold ☐☐ Cold Assessment ☐☐ Itchy ☐☐ Itchy
Foot: Foot:
☐☐ Rash present ☐☐ Rash present
☐☐ Hot ☐☐ Hot
☐☐ Fragile ☐☐ Fragile
☐☐ Warm ☐☐ Warm
☐☐ Weepy ☐☐ Weepy
☐☐ Cool ☐☐ Cool
☐☐ Shiny ☐☐ Shiny
☐☐ Cold ☐☐ Cold
☐☐ Hairless ☐☐ Hairless
☐☐ Mottled ☐☐ Mottled
Toes: Toes: ☐☐ Moist/waxy ☐☐ Moist/waxy
☐☐ Hot ☐☐ Hot ☐☐ Inflammation ☐☐ Inflammation
☐☐ Warm ☐☐ Warm ☐☐ Healed wound/scar ☐☐ Healed wound/scar
☐☐ Cool ☐☐ Cool ☐☐ Blister(s) present ☐☐ Blister(s) present
☐☐ Cold ☐☐ Cold ☐☐ Wound(s) present ☐☐ Wound(s) present
Circulation Dorsalis Pedis: Dorsalis Pedis: ☐☐ None of the above ☐☐ None of the above
☐☐ Present ☐☐ Present
Pulses by Sensation ☐☐ Numbness ☐☐ Numbness
☐☐ Diminished ☐☐ Diminished
Palpation ☐☐ Not palpable ☐☐ Not palpable Assessment ☐☐ Burning ☐☐ Burning
☐☐ Tingling ☐☐ Tingling
Posterior Tibial: Posterior Tibial: ☐☐ Crawling ☐☐ Crawling
☐☐ Present ☐☐ Present ☐☐ Intermittent ☐☐ Intermittent
☐☐ Diminished ☐☐ Diminished ☐☐ Continuous ☐☐ Continuous
☐☐ Not palpable ☐☐ Not palpable ☐☐ None of the above ☐☐ None of the above
Capillary Refill 3 seconds or less 3 seconds or less Pain ☐☐ Ache ☐☐ Ache
☐☐ Yes  ☐ No ☐☐ Yes  ☐ No Knife-like Knife-like
Assessment ☐☐ ☐☐
Comments ☐  See Progress Notes ☐☐ Intermittent ☐☐ Intermittent
☐☐ Continuous ☐☐ Continuous
☐☐ Non-verbal response ☐☐ Non-verbal response
☐☐ No pain ☐☐ No pain
Date (dd/mm/yyyy) Time Signature Printed Name

/ /
Form developed in collaboration with Fraser Health, Northern Health, Provincial Health Services, Vancouver Island Health, Vancouver Coastal Health & Interior Health
page 1 of 2
826502  Aug 29-14
 Client Name

DOB

ADVANCED LOWER LIMB ASSESSMENT PHN

FLOW SHEET Or addressograph / label

Parameter Right Lower Limb Left Lower Limb Parameter Right Lower Limb Left Lower Limb
Doppler: ☐☐ Present ☐☐ Present Foot ☐☐ Bunion(s) ☐☐ Bunion(s)
Diminished Diminished Assessment ☐☐ Callus(s) ☐☐ Callus(s)
Dorsal Pedis ☐☐ ☐☐
☐☐ Not audible ☐☐ Not audible ☐☐ Corn(s) ☐☐ Corn(s)
☐☐ Triphasic ☐☐ Triphasic ☐☐ Planter’s wart(s) ☐☐ Planter’s wart(s)
☐☐ Biphasic ☐☐ Biphasic ☐☐ Dropped metatarsal ☐☐ Dropped metatarsal
☐☐ Monophasic ☐☐ Monophasic head(s) head(s)
☐☐ Hammertoe(s) ☐☐ Hammertoe(s)
Doppler: ☐☐ Present ☐☐ Present ☐☐ Crossed toes ☐☐ Crossed toes
Posterior Tibial ☐☐ Diminished ☐☐ Diminished ☐☐ Fissures ☐☐ Fissures
☐☐ Not audible ☐☐ Not audible ☐☐ Cracks between toes ☐☐ Cracks between toes
☐☐ Triphasic ☐☐ Triphasic ☐☐ Abnormal skin dryness ☐☐ Abnormal skin dryness
☐☐ Biphasic ☐☐ Biphasic ☐☐ Acute Charcot ☐☐ Acute Charcot
☐☐ Monophasic ☐☐ Monophasic presentation presentation
Ankle Brachial Dorsal Pedis Pressure Dorsal Pedis Pressure
☐☐ Chronic Charcot ☐☐ Chronic Charcot
Index presentation presentation
Posterior Tibial Pressure Posterior Tibial Pressure ☐☐ None of the above ☐☐ None of the above
Brachial Pressure Brachial Pressure Toe Nail ☐☐ Incorrect length–short ☐☐ Incorrect length–short
Peroneal Pressure Peroneal Pressure Assessment ☐☐ Incorrect length–long ☐☐ Incorrect length–long
☐☐ Ingrown ☐☐ Ingrown
ABI Score ABI Score
☐☐ Unable to compress ☐☐ Unable to compress
☐☐ Involuted ☐☐ Involuted
☐☐ Thickened ☐☐ Thickened
arteries arteries
☐☐ Ram’s Horn formation ☐☐ Ram’s Horn formation
Toe Brachial Toe Pressure: Toe Pressure: ☐☐ Discoloured ☐☐ Discoloured
Pressure Index Brachial Pressure: Brachial Pressure:
☐☐ Thin ☐☐ Thin
☐☐ Ridged ☐☐ Ridged
TBI Score: TBI Score: ☐☐ Brittle ☐☐ Brittle
Monofilament ☐☐ Fungal infection ☐☐ Fungal infection
☐☐ 1st Digit ☐☐ 1st Digit ☐☐ None of the above ☐☐ None of the above
Testing ☐☐ 3rd Digit ☐☐ 3rd Digit Skin ☐☐ Blanching on elevation ☐☐ Blanching on elevation
10 Site Sensation Testing ☐☐ 5th Digit ☐☐ 5th Digit Assessment – ☐☐ Dependent rubor ☐☐ Dependent rubor
using a 5.07 gram monofilament
☐☐ Hemosiderin staining ☐☐ Hemosiderin staining
☐☐ 1st MTH ☐☐ 1st MTH Advanced ☐☐ Woody fibrosis ☐☐ Woody fibrosis
☐☐ 3rd MTH ☐☐ 3rd MTH (see Basic ☐☐ Venous dermatitis ☐☐ Venous dermatitis
☐☐ 5th MTH ☐☐ 5th MTH Assessment: Skin ☐☐ Atrophie blanche ☐☐ Atrophie blanche
for additional
☐☐ Medial ☐☐ Medial ☐☐ Contact dermatitis/pruritis ☐☐ Contact dermatitis/pruritis
Right Left
information)
foot foot
☐☐ Lateral ☐☐ Lateral ☐☐ Ankle flare ☐☐ Ankle flare
☐☐ Varicosities ☐☐ Varicosities
Check for sensation at each site ☐☐ Heel ☐☐ Heel
And also on the dorsum of each foot.
☐☐ Hyperkeratosis ☐☐ Hyperkeratosis
☐☐ Dorsum ☐☐ Dorsum ☐☐ Papillomatosis ☐☐ Papillomatosis
/ Score / Score ☐☐ None of the above ☐☐ None of the above
Pain ☐☐ With deep palpation ☐☐ With deep palpation
Positive Assessment – ☐☐ Relieved with elevation ☐☐ Relieved with elevation
Present:  ☐ Yes  ☐ No Present:  ☐ Yes  ☐ No ☐☐ Relieved with rest ☐☐ Relieved with rest
Stemmer’s Sign Advanced ☐☐ Relieved with dependent ☐☐ Relieved with dependent
(see Basic
Limb Shape ☐☐ Champagne-bottle ☐☐ Champagne-bottle position position
Assessment: Pain
shaped leg shaped leg ☐☐ Intermittent claudication ☐☐ Intermittent claudication
for additional
☐☐ Wasted calf muscle ☐☐ Wasted calf muscle ☐☐ Pain at night ☐☐ Pain at night
information)
☐☐ None of the above ☐☐ None of the above ☐☐ No pain ☐☐ No pain
Comments  ☐  See Progress Notes

Date (dd/mm/yyyy) Time Signature Printed Name

/ /
Form developed in collaboration with Fraser Health, Northern Health, Provincial Health Services, Vancouver Island Health, Vancouver Coastal Health & Interior Health
page 2 of 2