Wound Care Nurse Assessment Form

 Hello, my name is Rhonda. I am pleased that you are taking an active role in your wound care treatment. Please take a few moments to complete the following form so that I may best meet your needs. 

Submission of this form represents your compliance with the terms and conditions of iWOC Nursing Foundation. We will use your information strictly in accordance with our privacy policy.

A detailed medical history will allow me to provide you with the most accurate assessment of your individual wound care needs

*(denotes required field)

Name: *

E-Mail Address: *

Subject: *

Select Please help me with my wound.

Allergies (select all that apply) *

None
Iodine
Sulfa
Antibiotics

Relevant Medical Conditions (select all that apply) *

None
Coronary Artery Disease (Heart Disease)
Diabetes
Immobility
Infections (MRSA/VRE/C-difficile)
Kidney Disease
Leg Swelling
Obesity
Neuropathy (Altered Sensation)
Peripheral Vascular/Arterial Disease (Poor Circulation)
Poor Nutrition
Smoking
Steroid Use
Underweight

Wound Location (select one) *

Abdomen
Ankle
Back
Buttock
Chest
Coccyx
Ear
Elbow
Foot
Heel
Hip
Knee
Leg
Sacrum
Spine
Thigh
Toe

Origin of Wound (select one)

Infection
Injury
Spontaneous
Surgery
Unknown

Duration of Wound (select one)

Less than 2 weeks
2 weeks - 1 month
2-6 months
7-12months
Greater than 12 months

Drainage Amount (select one) *

None
Scant
Small
Moderate
Heavy
Continuous

Drainge Color *

None
Clear
Red
Pink
Yellow
Brown
Green

Drainge Consistency

None
Thick
Thin
Watery
Cloudy
Mucous

Drainage Odor

None Mild Strong

Wound Measurements (Length/Width/Depth)

Wound Size

Dime
Penny
Nickel
Quarter
Fifty-Cent
Dollar
Larger Than A Dollar

Pain *

None
Mild
Severe
Constant
Intermittent
Worse When Legs Elevated
Worse When Walking
Worse At Rest

Previous Successful Treatments

Previous Unsuccessful Treatments

Upload A Photo Of Your Wound

Acceptable file types: doc,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 1mb.

Additional Comments:

CAPTCHA Code: *