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Name
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Diagnosed
• • •
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when were you diagnosed
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since diagnosis what other problems have you had
• • •
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what medications were you started on?
• • •
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since diagnosis what meds have you started
• • •
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Current diet
• • •
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Diet consists of
• • •
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Have you seen a dietitian
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What other diagnosis have you had
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how often do you check your blood sugar
• • •
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How often do you exercise
• • •
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Sleep
• • •
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New PT Consult Form
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Pg 1-2
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Pg 5-6
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Pg 3-4
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Mini-Mental State Examination (MMSE)
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MME
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MMSE
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Assessment Questions
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Pg 1-2
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page 3-4
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Goldburg Depression
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Depression screen
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2nd page
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Michigan Neuropathy screen
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B. Physical Assessment (To be completed by health professional)
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1. Appearance of Feet
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Right Foot Normal
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Left Foot Normal
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If no, check all that apply:
• • •
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If no, check all that apply:
• • •
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If other is selected please specify:
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If other is selected please specify:
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2. Ulceration
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Right Foot
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Left Foot
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3. Ankle Reflexes
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Right Foot
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Left Foot
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4. Vibration Perception at Great Toe
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Left Foot
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Right Foot
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5. Monofilament
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Right Foot
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Left Foot
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Total Score
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neuropathy
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EQ-5D-5 Level
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EQ-5D-5 level
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VF-14 Questionnaire
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VF- 14
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PDQ- 39
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PDQ 39
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page 2
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(MMSE) Mini-Mental State Examination
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MMSE
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page 2
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photo or video
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Photo or video documentation
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another video
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3rd video or photo
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