Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Wound Care Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Wound Location & Duration
Wound Etiology / Type
Wound Size & Depth History
Pain Assessment
Prior Wound Treatments
Additional details
Current Dressing Regimen
Diabetes & HbA1c Status
Vascular Assessment History
Nutritional Status
Healing Risk Factors
Current Medications
| Medication | Dose | How often |
|---|---|---|
Please bring to your visit: wound photo
Consent & Signature
Date
Wound Care Intake Form template from formisoft.com. formisoft.com/intake-templates/wound-care-intake