DIABETIC FOOT ASSESSMENT FORM

KLINIK KESIHATAN:_________________________ DATE OF ASSESSMENT: ________

PERSONAL DATA
NAME:___________________________________ SMOKER: YES / NO
IDENTIFICATION CARD NUMBER: ________________________________
RISK FACTORS: □ Peripheral Arterial Disease □ Previous Diabetic Foot Ulcer
□ End Stage Renal Failure □ Previous amputation

Kindly (√) at the appropriate box if symptoms / abnormal findings are present

CURRENT SYMPTOMS Left Right Description

Paraesthesia (Pin & Needles) (_____) (_____)

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Intermittent Claudication (_____) (_____)
Resting Pain (_____) (_____)
Active foot ulcer (_____) (_____)
Prosthesis AF (_____) (_____)

Type of footwear Indoor Outdoor

GENERAL EXAMINATION Left Right Description

Skin changes or redness (_____) (_____)
Foot oedema / swelling (_____) (_____)
Corns / Callosities (_____) (_____)
Ulcers / Open wounds (_____) (_____)
Bunions (_____) (_____)
Lesser toe deformities (_____) (_____)
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Charcot Joints (_____) (_____)

Please draw/specify any abnormalities identified.

LEFT RIGHT
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NEUROLOGICAL EXAMINATION Left Right Description
Muscle wasting (_____) (_____)
Loss of proprioception (_____) (_____)
Loss of vibration perception (_____) (_____)

Semmes-Weinstein 10gram Monofilament Test

Left Right
1
2
3

6 5 4
10

8 7

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/10 9 /10
(intact) (intact)

VASCULAR EXAMINATION
Atrophic skin changes
Dystrophic nails
AF
Remark: (√) if intact, (×) if absent

Left
(_____)
(_____)
Right Description
(_____)
(_____)
Absence of hair (_____) (_____)
Abnormal temperature gradient (_____) (_____)
Capillary refill >3s (_____) (_____)

PALPABLE PULSES Left Right

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Dorsalis Pedis Artery (DPA) (_____) (_____)
Posterior Tibial Artery (PTA) (_____) (_____)
Popliteal Artery (PA) (_____) (_____)
Femoral Artery (FA) (_____) (_____)
Remark as either: ++ (Normal), + (Weak), - (Absent) or not done.
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ANKLE-BRACHIAL INDEX (ABI) Left Right

Brachial SBP (mmHg) (_____) (_____) Normal ABI ratio: 0.9 - 1.3
Dorsalis Pedis SBP (mmHg) (_____) (_____) ABI ratio < 0.9: Likely PAD
Posterial Tibial SBP (mmHg) (_____) (_____)
ABI (Ankle SBP / Brachial SBP)* (_____) (_____)
Note: SBP: Systolic Blood Pressure
*For ankle SBP: use either DPA or PTA whichever is higher

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Risk Stratification
Category Ulcer Risk Characteristics Screening Frequency
□0 Very Low No LOPS AND no signs of PAD Once a year
□1 Low LOPS OR PAD Once every 6-12 months
□2 Moderate LOPS + PAD or Once every 3-6 months
LOPS + foot deformity or PAD + foot deformity
□3 High LOPS or PAD + one of the following Once every 1-3 months
- a history of foot ulcer
- a lower extremity amputation (minor or major)
- end stage renal failure
Note: Loss of Protective Sensation (LOPS): Loss of either vibration perception and/or pressure
perception (abnormal monofilament test). Peripheral Arterial Disease (PAD): abnormal ABI / Weak
or absent pulses +/- history of intermittent claudication (if ABI unavailable)

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Management Plan
Foot care education
□ Foot hygiene □ Footwear advice (proper footwear, avoid barefoot)
□ Nail care □ Daily foot check (for any skin changes/infection/new ulcer)
□ Emollient use

Referral
□ MO
□ FMS
AF □ Advice to avoid massage/soaking/self-treatment
□ Wound care advice (if needed)

□ Wound Care Team

□ Vascular
□ Occupational Therapy □ Orthopedic
□ Physiotherapy □ Endocrine
□ Diabetic Educator □ Others: ________________________________

Follow up plan
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□ 1-3 monthly
□ 3-6 monthly
□ 6-12 monthly
□ Yearly
□ Next DFU screening due: __________________
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Name of Assessor: _____________________

Cop & Sign:

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