Wound Assessment Form
Date
-
Month
-
Day
Year
Date
Patient Name
First Name
Last Name
Patient ID Number
Assessor Name
First Name
Last Name
Patient
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
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
Tissue Type
Exudate Type
Exudate Level
Please Select
Dry
Low
Medium
High
Any Infections
Swab taken:
Yes
No
When
-
Month
-
Day
Year
Date
Result
Wound Edge Assessment
Periwound Tissue Skin Assessment
Treatment Plan
Management Goals
Treatment Choice
Follow Up Plan
Date of Next Visit
Main Objective at Next Visit
Submit
Should be Empty: