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Diabetic Shoes Checklist -Medicare Part B - AuBurn Pharmacies

WebComprehensive Diabetic Foot Exam & Shoe Order Form Required to satisfy Medicare requirement of in-person visit to determine need for shoes. Complete form for ordering … Web1. This patient has diabetes mellitus. 2. This patient has one or more of the following conditions. (Circle all that apply): a) History of partial or complete amputation of the foot b) History of previous foot ulceration c) History of pre-ulcerative callus d) Peripheral neuropathy with evidence of callus formation e) Foot deformity f) Poor ... incontrol windows 10

Diabetes Self-Management Education Patient Intake Form

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