Diabetic Foot Assessment Form
Patient Name
Date of Assessment
Age
Medical Record Number
History of Foot Ulcer
Yes
No
Amputation History
Yes
No
Loss of Sensation (Neuropathy)
Present
Absent
Peripheral Pulses
Present
Absent
Foot Deformity
Yes
No
Skin Changes (Callus, Dryness, Fissures, etc.)
Present
Absent
Active Ulceration
Yes
No
Infection
Present
Absent
Other Findings
Assessment Notes
Assessor Name
Signature