Wound Assessment Form
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Name
First Name
Last Name
Patient ID Number
Assessor Name
First Name
Last Name
Patient
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Age
Weight (kgs)
Gender
Please Select
Female
Male
Smoking
Please Select
Yes
No
Cigarettes per day:
Alcohol
Please Select
Yes
No
Mobility Status
Please Select
Good Mobility
Bad Mobility
Units per week:
Allergies
Diseases
Medications
Remarks
Wound Description
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Wound Type
Duration of Wound
Previous Treatments
Wound Length (mm)
Wound Width (mm)
Wound depth (mm)
Wound Location
Pain Level
If any pain, is it:
Constant
At dressing changes
Wound Assessment
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Tissue Type
Exudate Type
Exudate Level
Please Select
Dry
Low
Medium
High
Any Infections
Swab taken:
Yes
No
When
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Result
Wound Edge Assessment
Periwound Tissue Skin Assessment
Treatment Plan
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Management Goals
Treatment Choice
Follow Up Plan
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Date of Next Visit
Main Objective at Next Visit
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Submit
Should be Empty: