To obtain a monofilament, see the Resource List or the Order Form . Parts I through VII of this form may be completed by the physician or trained office staff. Part VIII should be completed and signed by the physician. I. Medical History Patients who have been diagnosed with any of the medical problems listed are likely to have had diabetes for several years and to be at risk for foot problems. If the patient is unable to feel the 10-gram monofilament on any site on either foot, he or she has peripheral neuropathy.
Current History Complete the questions as directed.
This question is to determine whether the patient has experienced any change in the strength or sensation in the feet. A positive history of a foot ulcer places the patient permanently in the high risk category. This person always has an increased risk for developing another foot ulcer, progressive deformity of the foot, and, ultimately, lower limb amputation. This question is to determine whether the patient experiences intermittent claudication when walking. This pain is an indication of peripheral vascular disease or impaired circulation.