Wound Care Intake Form

The Wound Care Intake Form is purpose-built for wound management practices, capturing the detailed wound history and contributing factor assessment that wound care specialists need for evidence-based treatment planning. This template collects patient demographics alongside a comprehensive wound assessment covering wound location, duration, suspected etiology (diabetic ulcer, venous stasis, arterial insufficiency, pressure injury, surgical wound, traumatic wound), size and depth history, drainage characteristics, surrounding skin condition, pain level and pattern, and prior wound treatments attempted (dressings, negative pressure wound therapy, hyperbaric oxygen, skin grafting, bioengineered tissues).

Designed for wound care centers, vascular surgery wound clinics, podiatric wound care, burn centers, and home health wound management programs, this form includes sections for contributing factors and comorbidities that impair healing (diabetes with HbA1c, peripheral arterial disease with ABI history, venous insufficiency, malnutrition, immunosuppression, radiation history, obesity, smoking), nutritional assessment (albumin, prealbumin, dietary intake, supplements), vascular evaluation history (ABI, duplex ultrasound, angiography), offloading and compression status for lower extremity wounds, current wound care supplies and dressing regimen, infection history and antibiotic use, and tetanus immunization status.

All fields are HIPAA-compliant and structured for the wound care evaluation workflow. The comprehensive pre-visit documentation allows the wound care specialist to review the wound trajectory, identify reversible barriers to healing, and arrive at the consultation prepared to assess the wound and modify the treatment plan. The structured format supports quality reporting metrics and documentation requirements for wound care certification programs.