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Assessment form

Please read and fill in the form carefully.

All fields marked with a * must be completed, otherwise the system will not let you submit the form.

Personal Details

OBSERVATION

Temperature / Hydratation

 

 

 

OBSERVATION

Skin appearance

VISUAL Symptoms - ULCER

Description

Foot structure - TOE Deformities

Foot structure

Arch Deformities / Ankle Deformities

Pain Sensation - PAD risk

VISUAL Symptoms - Varicose Veins - Venual Insufficiency


VASCULAR ASSESSMENT

TEST - Pedal Pulses

Weak / Absent - PAD risk

Weak / Absent - PAD risk

VASCULAR ASSESSMENT

Arterial TEST - Doppler Ultrasound

VASCULAR ASSESSMENT

VENUAL valve Insufficiency TEST - Doppler Ultrasound

 

It also a good test to be done when suspected DVT till more assessment can be done by vascular team!

At Popliteal Fossa

Venual backflow OK and NO Venuos reflux = Patent Valve function

Calf compression - Shooting/Prolonged Roar (Venual backflow OK)

Thigh compression - There is no audible signal 

Thigh relief - There is slight audible roar signal 

 

 

At Posterior Tibial artery

Venual backflow OK and NO Venuos reflux = Patent Valve function

ForFoot pressure - Shooting/Prolonged Roar (Venual backflow OK)

TEST - Capillaries Refill - Arterial deficiency

TEST - Buergen's - Arterial deficiency

 

Raise leg up 30-45 sec. Right / Left

Dangling leg down Right / Left

TEST - ABI - Arterial deficiency

 

ABI = 0.91-0.99 - Boarder line

ABI < 0.9 - PAD Risk

ABI = 1-1.4 Normal

ABI > 1.4 Calcification

TEST - Oedema

RIGTH

LEFT

Venual syst. insufficiency

Pitting oedema presented at ankles to mid‑calf.

Finger pressed into the swollen area for 1-3 sec. then lift away, it leaves a visible dent (“pit”) in the skin that slowly fills back out.

Lymphatic syst. insufficiency

Skin fold Cannot lift/pinched. The skin feels thick, tight, stuck.

Lymphatic syst. insufficiency

Skin fold Cannot lift/pinched. The skin feels thick, tight, stuck.

Venual syst. insufficiency

Pitting oedema presented at ankles to mid‑calf.

Finger pressed into the swollen area for 1-3 sec. then lift away, it leaves a visible dent (“pit”) in the skin that slowly fills back out.

NEUROLOGICAL ASSESSMENT 

TEST - Sensation 10g Monofilament

NEUROLOGICAL ASSESSMENT 

TEST - Sensation Vibration sense

(128 Hz tuning fork) at hallux / malleolus.

NEUROLOGICAL ASSESSMENT 

TEST - Sensation Temperature

USE OF PATIENT INFORMATION

To receive continuity and quality of care this information is recorded and may be shared with other members of the health care team involved in your care. We do not share your information with anyone who is not directly involved in your care.

PLEASE READ AND SIGN TO:

Confirm the information you have provided is accurate and that you understand this information will be held securely to ensure safe and effective care.

CONSENT FOR TREATMENT

Professionals are legally and ethically obliged to obtain informed consent prior to any treatment. At the first session, the professional will ask further questions and assess your condition. All necessary information and details will be discussed with you so that you can make an informed decision.

 You will be given time to consider the treatment options and what is suitable for you - Your consent can be withdrawn at any time

A professional may use sharp instruments and other equipment that may cause minor damage to the skin surface

After your consultation our practice normally is to write to your GP for good communication.

We use clinical photographs of the feet to monitor changes over time and to support your treatment. Images are stored securely as part of your clinical record and handled in accordance with UK GDPR.

Digital signature

NOTE: The Computer IP Address, along with date and time will be recorded when you click 'Submit'

Kovacs & Partners

FOOT HEALTH  I  NAIL CARE
Salisbury
Ringwood
Bournemouth
Poole
Southampton
Romsey
Ferndown
Wimborne
Winchester
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