Sensorimotor and Gait Training
Appendix 1: Michigan Neuropathy Screening Instrument.
History (To be completed by the person with diabetes)
1. Are your legs and/or feet numb? Yes No
2. Do you ever have any burning pain in your legs and/or feet? Yes No
3. Are your feet too sensitive to touch? Yes No
4. Do you get muscle cramps in your legs and/or feet? Yes No
5. Do you ever have any prickling feelings in your legs and/or feet? Yes No
6. Does it hurt when bed covers touch your skin? Yes No
7. When you get into the tub or shower, are you able to tell the hot water from the cold water? Yes No
8. Have you ever had an open sore on your foot? Yes No
9. Has your doctor ever told you that you have diabetic neuropathy? Yes No
10. Do you feel weak all over most of the time? Yes No
11. Are your symptoms worse at night? Yes No
12. Do your legs hurt when you walk? Yes No
13. Are you able to sense your feet when you walk? Yes No
14. Is the skin on your feet so dry that it cracks open? Yes No
15. Have you ever had an amputation? Yes No
Physical
Assessment
(To be completed by the health professional)
1. Appearance of
Feet
Right
Left
a. Normal Yes No Normal Yes No
b. If no, check all that apply: b. If no, check all that apply:
Deformities
Dry skin, callus
Infection
Fissure
Other
Specify:_______________
Deformities
Dry skin, callus
Infection
Fissure
Other
Specify:_______________
Right
Left
2. Ulceration Absent Present Absent Present
3. Ankle reflexes Present Reinforcement Absent Present Reinforcement Absent
4. Vibration
perception at
great toe
Present Decreased Absent Present Decreased Absent
5. Monofilament Normal Reduced Absent Normal Reduced Absent
Signature:
Total Score:
32 Pedorthic Footcare Association | www.pedorthics.org