Diabetic Foot Ulcer Assessment
Patient Information
Patient Name
Date of Assessment
Medical Record Number
Age
Sex
Male
Female
Other
Type of Diabetes
Type 1
Type 2
Other
Ulcer Details
Location
Duration (days)
Size (cm)
Depth
Superficial
Partial Thickness
Full Thickness
Wound Bed Appearance
Exudate Amount
None
Scant
Moderate
Heavy
Odor
None
Faint
Strong
Signs of Infection
Surrounding Skin Condition
Neuropathy / Vascular Assessment
Sensation (monofilament)
Intact
Reduced
Absent
Pedal Pulses
Normal
Reduced
Absent
Ankle-Brachial Index (ABI)
Additional Notes