Free Foot Assessment Tool Form - PDF Form Download

Download and use this form for your Patients if you are examining their Foot.

Foot Assessment Tool Form

Text Version of the Form

FOOT ASSESSMENT TOOL

PATIENT NAME ADMISSION # DATE

FUNCTION

CONDITION OF FEET LIMITS ACTIVITY □ YES □ NO
If yes, describe _______________________________________________

RESIDENT USUALLY WEARS SHOES
COVER FEET COMPLETELY □ YES □ NO
If no, describe ________________________________________________

NO YES BOTH
(R=RIGHT)
(L=LEFT)
SKIN
LESIONS

FISSURES BETWEEN/BENEATH TOES

OPEN SORES ON LEGS/FEET

CORNS

CALLUSES

PLANTAR WART

ITCHING LEGS/FEET

DRY, FLAKY SKIN
RASH

OTHER

TOENAILS
INGROWN

OVERGROWN

THICKENED

BROKEN

DISCOLORED

STRUCTURE/APPEARANCE
HALLUX VAGUS

HAMMER TOE

EDEMA

COLOR/TEMPERATURE PE (PALE) PK (PINK) R (RED) M (MOTTLED) D (DUSKY) B (BLACK)
W (WARM) CL (COOL) CD(COLD)
RIGHT COLOR TEMPERATURE

LEFT COLOR TEMPERATURE

PODIATRIST CONSULT RECOMMENDED □ YES □ NO

SIGNATURE NURSE PERFORMING ASSESSMENT________________________________

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