Diabetic Foot Exam Checklist Form
Complete this checklist to document a comprehensive diabetic foot examination. Select the findings that best match your clinical assessment.
Exam Consent & Acknowledgment:
By proceeding, you confirm that the patient has been informed about the purpose of this foot examination and has provided verbal consent. Complete this checklist as part of routine clinical care.
Skin Condition
*
Intact
Dry/Cracked
Callus
Blister
Other
Ulceration Present
*
No ulcer
Superficial ulcer
Deep ulcer
Signs of Infection
*
None
Redness
Swelling
Discharge
Odor
Foot Deformity
*
None
Hammer toes
Claw toes
Bunion
Charcot foot
Pedal Pulses
*
Both palpable
One palpable
Both absent
Monofilament Sensation (10g)
*
Normal (all sites felt)
Reduced (not all sites felt)
Absent (no sites felt)
Vibration Sense (Tuning Fork)
*
Normal
Reduced
Absent
Footwear Assessment
*
Appropriate fit
Worn out
Tight
Unsuitable style
Examiner Notes
Submit Checklist
Should be Empty: