Posterior Tibial Artery Assessment Form
Clinical assessment form for evaluating the posterior tibial artery. Please complete all fields based on your observations.
Patient Initials or Identifier
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Limb Assessed
*
Left
Right
Both
Palpation of Posterior Tibial Pulse
*
Absent
0
1
2
Normal
3
0 is Absent, 3 is Normal
Doppler Signal Quality
*
Triphasic
Biphasic
Monophasic
Absent
Capillary Refill Time (seconds)
*
Skin Temperature Compared to Opposite Limb
*
Cooler
Same
Warmer
Skin Color
*
Normal
Pale
Mottled
Cyanotic
Presence of Swelling
*
None
Mild
Moderate
Severe
Pain on Palpation
*
No pain
0
1
2
3
4
5
6
7
8
9
Severe pain
10
0 is No pain, 10 is Severe pain
Bilateral Comparison Table
Rows
Left Limb
Right Limb
Pulse Present
1
2
Doppler Signal
3
4
Capillary Refill <2s
5
6
Normal Color
7
8
No Swelling
9
10
Submit Assessment
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