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Free Foot Assessment Tool Form - PDF Form Download

Foot Assessment Tool Form Overall rating: ☆☆☆☆☆ 0 based on 0 reviews
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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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