Foot Care Assessment - Universal Health Hub

Patient Name *

Assessment Date *

What is the skin condition? *

Which Foot (Left or Right) and what location ? *

What is the Feet Condition? *

Which Foot (Left or Right) and Which Toe? Write which foot is this condition and which phalanx is affected *

What is the STRUCTURE-ANATOMY ? *

Which Foot (Left or Right) and what is the structural abnormality? *

What is the Sensation on the Feet? *

Normal sensation to 10 g monofilament exam
Subjective complaint of numbness, tingling, crawling or burning sensation
Absent sensation to 10 g monofilament exam at one or more sites (callous may give false negative finding
Pain or inflammation in a previously insensate foot
Normal sensation to tunning fork assessment

Which Foot (Left or Right) sensation is affected? *

What is the VASCULAR condition? *

Which Foot (Left or Right) vascular is affected? *

Footcare *

Footwear *

General comments/notes

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What service was done? *

Assessment Done by *

Signature *

Clear Signature