Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Wound Assessment & Documentation
Your information
Full Name *
Assessment Date
____ / ____ / ________
Wound Type/Etiology
Anatomical Location
Wound Dimensions (L x W x D)
Wound Bed Tissue
Exudate Type & Amount
Additional details
Periwound Skin Condition
Undermining/Tunneling
Please bring to your visit: wound photo
Pain Level During Care
Treatment/Dressing Applied
Healing Factors Assessment
Provider Signature
Date
Wound Assessment & Documentation template from formisoft.com. formisoft.com/intake-templates/wound-assessment