Feet

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Pain, weakness, stiffness, swelling, heat, redness, fatigability, lack of endurance, etc. Describe symptoms at rest and on standing and walking.
2. Describe symptoms at rest and on standing and walking.
3. Treatment - type, dose, frequency, response, side effects.
4. If there are periods of flare-up of joint disease:

1. State their severity, frequency, and duration.
2. Name the precipitating and alleviating factors.
3. Estimate to what extent, if any, they result in additional limitation of motion or functional impairment during the flare-up. (Per veteran)

4. Describe whether crutches, brace, cane, corrective shoes, shoe inserts etc., are needed and their efficacy.
5. History of any hospitalizations or surgery. (Date, location, if known, reason or type of surgery).
6. Describe effects of the condition(s) on the veteran's usual occupation and daily activities.
7. Describe any injury to the feet.
8. Functional limitations on standing (i.e. unable to stand, able to stand 15-30 minutes) and walking (i.e. nonambulatory, able to walk ¼ mile).
9. History of neoplasm:

1. Date of diagnosis, diagnosis
2. Benign or malignant
3. Types and dates of treatment
4. Date of last treatment

C. Physical Examination (Objective Findings)

Address each of the following as appropriate to the condition being examined and fully describe current findings: A detailed assessment of each affected joint is required.

1. Describe each foot separately. For nomenclature of toes use: great toe, second, third, fourth, and fifth. The functional loss should be related to the anatomical condition.
2. Describe objective evidence of painful motion, edema, instability, weakness, tenderness, etc.
3. Describe gait.
4. Describe any callosities, breakdown, or unusual shoe wear pattern that would indicate abnormal weight bearing.
5. Describe any skin and vascular changes.
6. Describe hammertoes, high arch, clawfoot, or other deformity - actively or passively correctable?
7. For flatfoot

1. Describe weight bearing and non-weight bearing alignment of the Achilles tendon.
2. Describe whether the Achilles tendon alignment can be corrected by manipulation and whether there is pain on manipulation.
3. Describe degrees of valgus and whether correctable by manipulation.
4. Describe extent of forefoot and midfoot malalignment and whether correctable by manipulation.

8. For hallux valgus, describe angulation and dorsiflexion at first metatarso-phalangeal joints.
9. Is there any active motion in the metatarsophalangeal joint of the great toe?

D. Diagnostic and Clinical Tests:

Comment on:

1. X-rays for flatfoot and clawfoot - weight bearing AP and lateral views and non-weight bearing AP, lateral, and oblique views, if none are of record or if of record and condition has or may have progressed.
2. For other conditions, AP lateral and oblique of entire foot as applicable.
3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: