SEARCH Michigan Neuropathy Screening Instrument (MNSI)

NEUROPATHY SCREENING INSTRUMENT
B. Physical Assessment (To be completed by the study personnel)
1.

Appearance of Feet
Right Foot
a. Normal
1
No 2 Yes
b. If no, check all that apply:

Left Foot
Normal 1 No 2 Yes
If no, check all that apply:

Deformities
Dry skin, callus
Infection

Deformities
Dry skin, callus
Infection

1
1
1

Fissure
Other
specify:

1
1
1

Fissure
Other
specify:

1
1

1
1

Right Foot
2.

3.

Ulceration
Present

Absent

Present

1

2

1

2

Present/
Reinforcement Absent

1

2

Present

3

1

Absent

Present

3

1

Present/
Reinforcement Absent
2

3

Vibration perception at the great toe*
Present

Reduced

1

5.

Absent
Ankle Reflexes
Present

4.

Left Foot

2

Reduced
2

Absent
3

10 gm filament (number of applications detected out of 10 applications):
Present (≥ 8)
1

Reduced (1-7)
2

Absent( 0)
3

Present (≥ 8)
1

Reduced (1-7)
2

Absent( 0)
3

*Vibration is Present if the examiner feels vibration on his finger joint for 10 seconds or less after the patient reports vibration
at toe has stopped. Vibration is Reduced if examiner feels vibration for more than 10 seconds after patient reports vibration at
toe has stopped. Vibration is Absent if patient does not perceive any vibration from the tuning fork.

SEARCH 3 Michigan Neuropathy Screening Instrument Form - Revised 12 30 2010

FOR STUDY USE ONLY
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Reviewed
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SEARCH 3 Michigan Neuropathy Screening Instrument Form – Revised 12-30-10

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by
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