Diabetes Foot Exam Form
Please fill out this form to assess the condition of your feet if you have diabetes.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Examination
 -
Month
 -
Day
Year
Date
Medical History
Have you experienced any of the following symptoms in your feet?
Numbness or tingling
Pain or discomfort
Burning sensation
Swelling
Changes in skin color or texture
Open sores or ulcers
Corns or calluses
Ingrown toenails
Blisters
Other
Rate the severity of your foot symptoms on a scale of 1 to 10 (1 being mild, 10 being severe):
1
2
3
4
5
6
7
8
9
10
Please describe any observed changes in your feet, such as redness, swelling, or wounds:
Do you inspect your feet regularly?
Yes
No
Have you ever received a diabetic foot examination before?
Yes
No
If yes, when was your last diabetic foot examination?
 -
Month
 -
Day
Year
Date
Do you have a history of foot problems or complications related to diabetes?
Yes
No
If yes, please provide details:
Have you ever experienced loss of sensation in your feet?
Yes
No
Do you wear any protective footwear?
Yes
No
Submit
Should be Empty: