Timely Neuropathy Testing

 

                                    FOOT SCREEN FORM

 
 
 
Grade as indicated below:
 
Right
Left
Grade 
Foot Risk Category (WHO grade)
 
 
0
No Protective Sensory Loss  (Feels Orange 5.07 10 gram level monofilament)    
 
 
1
Loss of Protective Sensation (No deformity or plantar ulcer history) (Does not feel  orange 10 gram level monofilament)
 
 
2
Loss of Protective Sensation and Deformity (No plantar ulcer history) (Does not feel  orange 10 gram level monofilament)
 
 
3
History of Plantar Ulcer (Does not feel  orange 10 gram level monofilament)