Absent Dorsalis Pedis and Posterior Tibial Pulse. If one foot pulse palpable then PVD unlikely

1. Annual Diabetes Foot Assessment. Date Patient Name Address DOB Tel Number GP Hospital or NHS number Section 1 Type 1 / Type2 / Type 2 treated with insulin. Glycaemic Control Good / Unstable / Poor. Latest HBA1c if known …...%. Date……….. Year Diabetes Diagnosed …… Medication History of: Diabetes Eye Problems / Diabetes Kidney Problems M I/ Stroke Smoker Yes / No Anticoagulant Therapy Yes / No Absent Dorsalis Pedis and Posterior Tibial Pulse. If one foot pulse palpable then PVD unlikely Less than 10/10 Monofilaments Reactions. Previous history of ulcer or amputation Section 2 Please note comments in italics LEFT RIGHT RIGHT LEFT Atrophy of skin/ friable tissue Foot deformity (Clawing Toes/ Bunion/ High Arched Foot/ Charcot ) Unsuitable footwear If no other risk factors offer education advice. Refer to Podiatry if foot pathology present. Presence of callus or abnormal nails Poor vision restricting ability to care for feet. • Please refer patient to Dept Foot Health, Arundel Building, Brighton General Hospital if any of section 2 boxes are ticked. Section 3 At Risk Category (please tick) Referral made by; Name Base Designation • Low current risk – normal sensation and palpable pulses • At risk – neuropathy, absent pulses or other risk factor • High risk – neuropathy or absent pulses plus deformity or skin changes or previous ulcer. • Foot care emergencies – new ulceration, swelling or discolouration. Review Date. / / If required please refer Diabetes Foot Ulcers to Podiatry, Diabetes Centre, RSCH. Comments or reason for referral