Diabetic Foot Exam Form

Lets clinical staff record the symptoms and findings of a diabetic foot exam in a structured way.

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Full name

First Name

Last Name

Email address

Phone number

Date of examination

Have you experienced any of the following foot symptoms?

Numbness Tingling Pain Swelling Redness Wounds or sores

Rate the severity of your foot symptoms

Mild (1-3) Moderate (4-6) Severe (7-8) Very severe (9-10)

Describe any changes you've noticed in your feet, such as redness, swelling, or wounds

Do you inspect your feet regularly?

Yes No Sometimes

Have you had a diabetic foot exam before?

Yes No

If yes, when was your last diabetic foot exam?

Do you have a history of diabetes-related foot problems?

Yes No

If yes, please provide details

Have you experienced loss of feeling in your feet?

Yes No

Do you wear protective footwear?

Yes No Sometimes

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