Contact Details

Date of Initial Consultation:

Client's Name:

Date of Birth:

 

Street addressStreet address line 2

Suburb

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Podiatry Initial Assessment

Referrer Details

Referrer Company:

Key Contact Name:

Phone/Mobile:

Email:

Consent

 

ProvidedNot providedVerbalWritten

Further Information:

Consumer Assessment

Consumer Assessment

Reason for Referral

Client is unable to:

Client is unable to self-manage foot care, secondary to hip, knee inflexibility, vision impairmentOther

Provide Further Information:

Subjective

 

Have you noticed any changes in your feet or legs recently?

YesNo

Please provide details

Are your feet stopping you from moving around safely?

YesNo

Please provide details

Do you feel comfortable and steady on your feet?

YesNo

Please provide details

What do you want to stay able to do (e.g. walking, shopping, standing to cook, etc.)?

YesNo

Please provide detailsADLs

Do you need help to care for your feet so you can stay mobile and independent?

YesNo

Please provide detailsOngoing regular podiatry care

Goals

• Assess foot health 

• Assess vascular, neurological, dermatological, biomechanical and footwear status of patient's feet 

• Education provided to improve foot health 

• Perform general nail & skin care 

• Assess for further health referrals/interventions 

• Liaise with other health professionals to reach patient goals

• Regular podiatry assessment and treatment to maintain optimal foot condition and prevent complications
  

Medical History

 Refer to client medical summary in file

Medications

 

Allergies

 

Social Situation

 

Lives aloneLives with familySupportive neighbours/familySupported environment (i.e. RAC or serviced units)Other

Provide further details:

Assessment

Assessment

Vascular Assessment

Pedal pulses:

Pedal pulses palpable in both feetPedal pulses impalpable in both feet

Provide further detail:

Skin colour/temperature:

Within normal limitsFragile skin integrity

Provide further detail:

Vascular Assessment:

Varicosities evidentHaemosiderin evidentOedema evident

Provide further detail:

Doppler arterial ultrasound:

Triphasic (strong)Biphasic (moderate)Monophasic (weak)IrregularAtrial fibrillation

Provide further detail:

Neurological Assessment

Monofilament detected at (right):

Monofilament detected at (left):

Vibration detected at (right):

Vibration detected at (left):

Parasthesia:

Motor neuropathy:

Autonomic neuropathy:

Dermatological Assessment

Nails:

Nail length:

Nail Health:

Healthy toenailsOnychomycatic toenails (fungal toenails)Onychauxic (thickened toenails)Ingrown toenails

Skin:

 

Xerotic (dry) condition

Interdigital spaces inspected:

Within normal limitsMaceration present

Hyperkeratosis (callus) present on (if applicable):

Right forefootLeft forefootRight Apices of toeLeft Apices of toeRight HeelLeft Heel

Skin:

Heloma Dura (Corns)Verruca pedisTinea pedisDermatitisOther

Provide further details:

Biomechanical Assessment

Orthopaedic deformity:

Grade HAV (bunion)Bone deformity Bony prominence

Bunion Grade:

Biomechanical Assessment:

Pressure areas at risk of breakdown:Nil orthopaedic deformity

Provide further details:

Footwear Assessment

 

Appropriate (supportive heel counter, sturdy sole, fixation)Inappropriate (flexible heel counter and sole, nil fixation)OrthosesOther

Provide further details:

Treatment and Education

Treatment & Education Provided

Dermatological

 

Pre & Post wipe over with pre-op chlorhexAll nails trimmed, cleared, & burredCallus sharp debridedCorns sharp debridedInterdigital spaces checked and cleared of any skin debrisEmollient appliedPatient advised to apply emollient on a regular basis to improve skin integritySkin smoother with MDPatient advised to:

Provide further details:

Sterilization

Date:

Batch:

Vascular

Vascular results indicate:

Adequate blood supply for healingReduced blood supply which may cause delay in healingDiscussed vascular results with patient

Provide further details:

Neurological

Neurological results indicated:

Protective sensation intactLoss of protective sensationDiscussed neurological assessment results with patient

Provide further details:

Biomechanical

Discussed results (advised):

Footwear

 

Education & Referral ProvidedCommunication with Care Manager regarding assessment and referral for appropriate footwear

Provider further details (if applicable):

Referrals & Reviews

Referrals

Referrals Required

Imaging:

X-RayUltrasoundOther

Provide further details:

Other health professionals:

Management Plan

Seek funding

 

Moisturising CreamFootwearInterdigital DeviceCompression StockingsOther:

Provide further details:

Would you like regular foot checks to keep on top of any foot problems and/or prevent possible complications?

YesNo

Provide further details:

Recommendations and Clinical Justification

 

Initial consultation: 1 hour durationReview appointment: 30 minutesAppointments: 6 weekly basisOther

Provide further details:

Review

Review frequency:

Goals:

Podiatrist name:

Podiatrist email:

Podiatrist signature:

Draw signature|Type signatureClear

Date:

 

This is the final copy of the assessment and will be sent to the referrer email address

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