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TAP Mobility AP SCREENING FORM RevA Jan21

This document contains a screening form to assess an individual's mobility needs and risk of foot wounds. It collects information on demographics, health history, mobility, foot screening, and identifies appropriate assistive products or referrals. Key sections include a foot screening checking for risk signs like wounds or reduced sensation, and simple questions to determine if walking aids, wheelchairs, ramps or grab bars could help. The form summarizes foot wound risk and outlines a plan for products, education, referrals and follow up.

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Dav
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60 views2 pages

TAP Mobility AP SCREENING FORM RevA Jan21

This document contains a screening form to assess an individual's mobility needs and risk of foot wounds. It collects information on demographics, health history, mobility, foot screening, and identifies appropriate assistive products or referrals. Key sections include a foot screening checking for risk signs like wounds or reduced sensation, and simple questions to determine if walking aids, wheelchairs, ramps or grab bars could help. The form summarizes foot wound risk and outlines a plan for products, education, referrals and follow up.

Uploaded by

Dav
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Screening Form: Mobility assistive products

1. Information about the person


First Name: Family Name:

Gender: Male Female Other Age: 0-5 6-18 19-39 40-54 55+
Telephone: Address:
2. Simple mobility and health risk check

Ask the following questions


Loss of Has your mobility reduced a lot Yes No
Refer to health care service
mobility in the past three months?
Children’s Is the child two years or more
Yes Refer to rehabilitation service No
mobility and not able to walk?
Risk of Do you worry about falling, or have you Yes Provide assistive product No
falling fallen more than once in the past year? Refer to rehabilitation service
Pressure Do you have a pressure wound on your Advise to avoid pressure on
Yes No
wounds body (such as hips, buttocks, back)? wound and refer to health
care service for wound care

Risk of Have you had: Foot wound Amputation If any


foot Do you have: Foot wound, injury or swelling Diabetes Leprosy Complete
wound foot screen
Heart and/or kidney If any Check person is visiting health
disease care service regularly. If not Refer. below

Do you: Smoke Drink alcohol (a lot) Often walk barefoot

3. Foot screen (complete if person answers yes to any risk of foot wound questions)

Look closely at the top and bottom of the person’s feet and between their toes
Has the person had before: Foot wound A toe, foot or leg amputation If any
Does the person have now: A toe, foot or leg wound or injury High risk sign

Is either foot: Red Hot to touch Swollen


Can you see any: Skin / nail problems Unusual shape of foot / toes Risk sign
Check blood flow

Can you see signs of Ankle or foot swelling No hair on feet or toes If any
reduced blood flow: Cold or pale foot Risk sign
Ask: Do you feel pain in
At night While walking less than 200 metres
the back of your legs?
Pulse test No pulse
Left foot: Top Ankle Right foot: Top Ankle
Risk sign

Refill test: Push end of each big toe firmly. Refill less than 3 secs
Count seconds for toe to return (refill) to normal colour. Refill more than 3 secs Risk sign
Check feeling (sensation)
Ask: Do you have any unusual feelings or pain in your feet or toes? Yes Risk sign
Sensation test: With person’s eyes closed If person can’t feel
3 1 1 3
- touch tip of toes 1, 3 and 5, switching to 2 or more toes
the other foot after each touch. 5 5
Tick toes that feel Right Left Risk sign
Cross toes that do not feel Foot Foot

Referral recommended Write notes here

TAP Mobility AP SCREENING FORM RevA Jan21.pdf Page 1 of 2


Summarise the person’s foot wound risk (count the number of risk and high-risk signs ticked)
Number of risk signs ticked Level of foot
Risk High risk wound risk

0 or 1 Teach about suitable shoes


0 Low
Teach how to care for feet
2 0 Moderate Teach how to care for feet
Assess for therapeutic footwear and/or
3+ 1 High Refer to health care service or foot wound clinic
4. Simple screening questions for mobility assistive products

Walking aid and/or wheelchair


Can you Yes, without difficulty No action
stand and
Yes, with assistance If any Assess for walking aid and discuss
walk?
Yes, only short distances referral for wheelchair assessment
Yes, on one leg only
No, cannot walk at all Refer for wheelchair assessment
Portable ramp (only for people who use a wheelchair, rollator or walking frame)
Do you need to get up and down a few steps Yes A portable ramp may assist
and/or in and out of a vehicle regularly? No

Grab bar (for example in the bedroom, toilet, bathroom, or by steps)

Do you have difficulty around your home moving in Yes Grab bars may asssit
bed, balancing, sitting up, standing up or moving? No

Transfer board (for example to move to and from the bed, toilet, sofa or vehicle)

Do you have difficulty moving your body Yes A transfer board may assist
from one place to another? No

Prosthetic foot or leg (for people with a leg or foot amputation)


Yes Check prosthesis refer to prosthetics service if any concerns
Do you use a prosthesis?
No Discuss if a referral to a prosthetic service is needed

5. Other assistive products


Do you have Seeing Hearing Self care If any Other assistive
difficulty with: products and/or referral to
Communication Cognition (thinking / remembering) other services may be needed

6. Plan

Screen for: Seeing Hearing Self care Communication Cognition

Assess for: Walking aids Portable ramp Grab bars in the home
Transfer board Therapeutic footwear

Teach about: How to care for feet Suitable shoes to wear

Refer to Health care Wound care Rehabilitation Wheelchair


other Diabetes care Foot wound clinic Prosthetic review or assessment
service for:
Other:

Follow up in: 1-3 months 6 months 12 months Follow


up date:

Referral recommended Write notes here


TAP Mobility AP SCREENING FORM RevA Jan21.pdf Page 2 of 2

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