Follow up chart for determining Effectiveness of Diabetes Foot Care program on

patients.

Name of the patient:

Age:
Address:
Phone number:
Type of DM:
History of Diagnosing with DM:
Level of Education:
Follow up series:
Date of follow up:

Yes:1 No: 0

1 Did you Check your feet daily? Yes ☐ No ☐

2 Did you wash your feet daily? Yes ☐ No ☐

3 Did you use skin Cream, lotion or jell? Yes ☐ No ☐

4 Did you Check for Calluses and Corn? Yes ☐ No ☐

5 Did you trim your toenails regularly? Or by help of others? Yes ☐ No ☐
6 Did you use shoes and socks always during walking? Yes ☐ No ☐
7 Did you protect your feet from hot and cold? Yes ☐ No ☐
8 Did you use the techniques for enhancing blood Circulation Yes ☐ No ☐
9 Did you do feet exercises? Yes ☐ No ☐
10 Did you check your feet in clinic if you noticed an abnormality Yes ☐ No ☐
11 Did you take your medications Correctly? Yes ☐ No ☐
12 Did you monitor your blood glucose daily? Yes ☐ No ☐
Total Score: