Diabetic Foot Screening Form

Diabetic Foot Screening Form — Form Fields

This healthcare template includes 8 fields. Diabetic foot screening form for assessing circulation, sensation, and skin integrity in patients with diabetes. Used by podiatrists, endocrinologists, and primary care providers. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Years Since Diabetes Diagnosis (number, required)
• Diabetes Type (dropdown selection, required) — options: Type 1, Type 2, Gestational, Other / Unknown
• History of Foot Ulcers? (multiple choice, required) — options: Yes, No
• Current Foot Symptoms (select all that apply) (checkboxes, optional) — options: Numbness or tingling, Burning sensation, Cold feet, Open sores or cuts, Calluses or corns, Discoloration, None
• Can you feel the monofilament test on both feet? (multiple choice, required) — options: Yes, both feet, Left foot only, Right foot only, Neither foot
• Footwear Type (dropdown selection, required) — options: Diabetic / therapeutic shoes, Athletic shoes, Casual shoes, Sandals / open-toe, Goes barefoot frequently
• Examiner Notes (long text, optional)