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Diabetic Foot Ulcer Referral Tool Diabetic Foot Referral Tool
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Harmonized Risk Assessment Tool

To use this tool to build your patient’s diabetic foot ‘dream team’ you must have screened their feet using a valid diabetic foot screening tool and then determined their risk level (low, moderate or high) using the Diabetic Foot Ulcer Risk Stratification & Referral Algorithm.

NOTE: Tools are only useful if they are evidence-informed, relevant to the characteristics of the target population and if clinical education and organizational and systemic supports are in place7-8

Diabetic Foot Ulcer Risk Stratification and Referral Algorithm

Risk 0
Risk 2a
Risk 3a
Risk 1
Risk 2b
Risk 3b

Risk 0 - Low foot ulcer risk

Q yr assessment with
  • Primary care monitoring
  • Give structured self-care info- Refer to www.swrwoundcareprogram.ca for patient self-management resources
  • Your team should include a local Diabetes Support Program/Dabetes Education Program/Diabetes Education Centre 

Risk 1 - *Neuropathy < 6/10 sensitivity on either foot to monofilament testing (assessment tips on flip side of pg. 1)

Q6/12 With a “Moderate Risk Service” 
  • Access the Diabetic Foot Ulcer Tool to build your interdisciplinary team
  • Give structured self-care information from www.swrwoundcareprogram.ca
  • Moderate Risk Services include a health care provider with an expertise in diabetes management, chiropodist or foot services with expertise in diabetes and foot deformity

Risk 2a - *Neuropathy < 6/10 monofilament sensitivity on either foot AND *Deformity

Q3/12 With a “Moderate Risk Service” such as
  • Access the Diabetic Foot Ulcer Tool to build your interdisciplinary team
  • Give structured self-care information from www.swrwoundcareprogram.ca
  • Moderate Risk Services include a health care provider with an expertise in diabetes management, chiropodist or foot services with expertise in diabetes and foot deformity

Risk 2b - HX PAD OR *Absence of both PT & DP pulses on either foot

Q3/12 With a “Moderate Risk Service” such as
  • Access the Diabetic Foot Ulcer Tool to build your interdisciplinary team
  • Give structured self-care information from www.swrwoundcareprogram.ca
  • Moderate Risk Services include a health care provider with an expertise in diabetes management, chiropodist or foot services with expertise in diabetes and foot deformity

Risk 3a - PHx Ulcer / Active Ulcer

Q1-4/12 With a “High Risk Service” such as
  • SJHC Parkwood Institute     (Fax) 519-685-4027
  • SJHC PCDSP                      (Fax) 519-645-6961
  • London Diabetic Foot Clinic (Fax) 519-432-6266
  • GBHS                                   (Fax) 519-371-7695
  • West Elgin CHC                   (Fax) 519-768-2548
  • AMGH                                  (Fax) 519-524-8527
Specialty Site Referral Form for Primary Care 

Risk 3b - PHX Amputation

Q1-4/12 With a “High Risk Service” such as
  • SJHC Parkwood Institute     (Fax) 519-685-4027
  • SJHC PCDSP                      (Fax) 519-645-6961
  • London Diabetic Foot Clinic (Fax) 519-432-6266
  • GBHS                                   (Fax) 519-371-7695
  • West Elgin CHC                   (Fax) 519-768-2548
  • AMGH                                  (Fax) 519-524-8527
Specialty Site Referral Form for Primary Care 
*Adapted from St. Joseph's Health Care London "Diabetic Foot Ulcer Risk Stratification & Referral Algorithm"

Diabetic Foot Ulcer Risk Stratification Referral Algorithm Click here
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