Diabetic Foot Care Assessment

Diabetic Foot Care Assessment — Form Fields

This healthcare template includes 15 fields. Foot care assessment form for diabetic patients to monitor and prevent complications. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Patient ID (text, required)
• Date of Assessment (text, required)
• Years with Diabetes (number, required)
• Diabetes Type (dropdown selection, required) — options: Type 1, Type 2, Gestational, Pre-Diabetes
• Most Recent A1C (%) (number, optional)
• Peripheral Neuropathy Diagnosed (multiple choice, required) — options: Yes, No, Suspected
• Peripheral Vascular Disease (multiple choice, required) — options: Yes, No, Suspected
• Current Foot Symptoms (checkboxes, optional) — options: Numbness, Tingling, Burning, Pain, Swelling, Color Changes, Temperature Changes, None
• Open Wounds or Ulcers Present (multiple choice, required) — options: Yes, No
• Monofilament Test Result (dropdown selection, optional) — options: Normal Sensation, Decreased Sensation, Absent Sensation
• Pedal Pulse (dropdown selection, optional) — options: Strong, Weak, Absent, Not Assessed
• Skin Condition (dropdown selection, required) — options: Healthy, Dry/Cracked, Callused, Fungal Infection, Discolored, Ulcerated
• Footwear Assessment (checkboxes, optional) — options: Proper Fit, Too Tight, Too Loose, Worn Out, Inappropriate Style
• Treatment Plan and Recommendations (long text, required)