Type 1 Type 2 Rx - Insulin - Incretin - Oral Hypoglycemic - Diet Diabetes duration Attending MD Height BP Weight Date: Age: History of: HbA1C Foot Ulcer Infection Amputation Revascularization Renal Disease CAD Stroke Tobacco Alcohol Numbess Burning Paresthesia/Tingling Sharp Pain Night Pain Muscle Weakness Gait Difficulties Claudication toes plantar feet to above ankle . to below knee night daily occasionally wheelchair walker cane brace foot orthosis MDI Shoes Skin: Turgor Color Temperature Texture Fissures Corns Calluses Ulcers Lesions Nails Musculoskeletal Mark areas of callus, ulcer or pre-ulcer, erythema, swelling, tenderness or deformity Joint Flexibility Deformities or Sites of High Pressure Gait assessment .
