DIABETES / NEUROVASCULAR ASSESSMENT

 

Name ____________________________________­­­­­­­­­_________________ Date of Birth ______________  Today’s date_______________

 

Type of diabetes:  IDDM / NIDDM / GDM                 Diabetes Diagnosed Date_______________________________________________

 

Occupation _______________________________________ Exercise _______________________________________Smoker  YES / NO

 

Health _____________________________________________________________________________________________

 

VASCULAR ASSESSMENT

 

  • Pulses                  0           = absent               m – monophasic waveform (sound only)

+            = weak                 b – biphasic waveform (sound only)

++        = normal              t – triphasic waveform (sound only)

+++        = bounding

Date

L           R L           R L           R L           R L           R L           R
DP
PT
PP
IC

 

Intermittent Claudication (Calf/Buttocks)

Night Cramps / Rest Pain (feet, i.e. hang feet over the edge of the bed)

 

SPVPFT apex of hallux (norm = 3secs) L_______secs        R_______secs Previous vascular surgical intervention

Ischaemic changes

Anti-coagulant medication

 

 

NEUROLOGICAL ASSESSMENT

 

  • Sensitivity to 5.07 (10gram) Semmes-Weinstein monofilament                                           X indicates insensate area
  • Tuning Fork – Vibration test                                                                                   °  indicates insensate area
  • Proprioception response hallux

 

Date________   Symptoms____________ Date________  Symptoms ___________

 

Date________   Symptoms____________ Date________   Symptoms____________
Date________   Symptoms____________ Date________   Symptoms____________

 

 

TEMPERATURE ASSESSMENT   < 2 degrees is WNL

Date: Date: Date: Date: Date: Date:
  L             R Difference   L             R Difference   L             R Difference   L             R Difference   L             R Difference   L             R Difference

 

STRUCTURAL

 

  • Structural deformity: prominent IPJs / prominent MPJs / bunion deformity / rocker bottom foot / other ___________________________

 

  • Hyperkeratosis: where / degree ____________________________________________________________________________________

 

  • Nail deformity: ingrown / thickness / mycosis_________________________________________________________________________

 

SELF CARE

 

Visual Acuity:  Good / Impaired                                                                Ability to reach feet:  Yes / No

 

Social support _______________________________________________________________________

Current foot care performed by _________________________________________________________________

 

General condition of feet _______________________________________________________________________

 

Footwear _______________________________________________________________________

 

Knowledge________________________________________________________________

 

 

ULCERATION

 

Past Ulceration / Amputation _______________________________________________________________________________________

 

_______________________________________________________________________

 

CONCLUSION

VASCULAR     NEUROLOGICAL     STRUCTURAL     ULCERATION     SELF CARE                 RISK

 

INTERVENTION / RECOMMENDATIONS

Vascular_________________________________________________________________

Neurological_______________________________________________________________

Structural________________________________________________________________

Ulceration________________________________________________________________

Self Care_______________________________________________________________

 

Other

 

 

 

 

 

DATE OF NEXT ASSESSMENT:

We are located in Perth (south of the river) in Wilson, which is neighboured by Curtin University, Como, Manning, South Perth, Victoria Park, Bentley, St James, Cannington / Carousel, Riverton, Shelley, Ferndale, Lynwood, Parkwood, Willetton and surrounding suburbs.

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