Date: ___________________
Interprofessional Diabetes Foot Ulcer Team
310 Wellington Road, London N6C 4P4
Initial Patient History Form
Patient name:______________________________________
Date of birth:_________________
SURGICAL HISTORY
MEDICAL PROBLEM LIST
Diabetes Type:  Type 1
 Type 2
Diabetes Duration:___________________________
HbA1c: ____________date: _______________
Diabetes control   7%  requires improvement
Diabetes Complications:
 Renal impairment  Hypertension  Retinopathy
 History of previous foot ulcers  Dyslipidemia  Stroke
 Peripheral Arterial Disease  Cardiovascular Disease
 Obesity  Mental/Affective Disorder
MEDICATIONS
Other medical problems:
 Obesity  Mental/Affective Disorder
 History of falls. Details: ___________________________________
Other:
FAMILY HISTORY:
SOCIAL HISTORY
Marital Status:  Married  Common-law  Widowed
 Separated/Divorced  Same-sex partner  Single
Living Situation:  Lives alone partner/spouse roommate
 dependent children  adult children  parents/in-laws
 other___________________________
Best source of support re Illness:  spouse/partner  child
 parent  sibling  friend  other_______________
Support Person’s Response to Illness:
 understands their illness
 understands their need for medication
 understands their need for treatment
 encourages their coping efforts
 provides practical help
 sometimes tries to take over management
 understands chronic-nature of illness  supports and listens
to challenges
SOCIAL HABITS:
Alcohol:  No  Yes glasses/wk__________________
Smoker?  Never  Yes: Amount __ppd x __ yrs QUIT______
Drugs:
9th July 2010
ULCER WOUND HISTORY (duration, recurrence, infection, hospitaln)
DATE OF ONSET/DURATION:
TREATMENTS: CURRENT
TREATMENTS: PAST
Response to Treatments (e.g., wearing new footwear occasionally, stopped
smoking entirely, using meds regularly) :
Barriers to Treatment (e.g., depression, family problems, difficulty
remembering to check feet)
Weight bearing activity level problematic :  No  Yes
Work:______________________________________________
Exercise:___________________________________________
Social activities:______________________________________
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