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Diabetic Foot Screening Form - Free Healthcare Template | ZenBuild | ZenBuild

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Diabetic Foot Screening Form

Diabetic foot screening form for assessing circulation, sensation, and skin integrity in patients with diabetes. Used by podiatrists, endocrinologists, and primary care providers.

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Diabetic Foot Screening

Please complete this screening form to assess foot health and risk factors.

Patient Name*

Years Since Diabetes Diagnosis*

Diabetes Type*

History of Foot Ulcers?*

YesNo

Current Foot Symptoms (select all that apply)

Numbness or tinglingBurning sensationCold feetOpen sores or cutsCalluses or cornsDiscolorationNone

Can you feel the monofilament test on both feet?*

Yes, both feetLeft foot onlyRight foot onlyNeither foot

Footwear Type*

Examiner Notes

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

Uses0

Views1

healthcarediabetespodiatryscreening