Digital Ulcer Assessment Form
Please complete all sections to assess the current status of the digital ulcer.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Ulcer Location
*
Please Select
Right index finger
Right middle finger
Right ring finger
Right little finger
Left index finger
Left middle finger
Left ring finger
Left little finger
Thumb
Other
Ulcer Duration (in days)
*
Ulcer Appearance Assessment
*
Rows
Score (0-3)
Size (0: none, 3: >1cm)
Depth (0: superficial, 3: deep/exposed tissue)
Edge (0: well-defined, 3: undermined/irregular)
Base (0: healthy, 3: necrotic/slough)
Pain Level
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible
10
0 is No pain, 10 is Worst possible
Exudate Amount
*
None
Scant
Moderate
Heavy
Signs of Infection
*
Redness
Swelling
Warmth
Increased pain
Purulent discharge
None
Periwound Condition
*
Healthy
Macerated
Erythematous
Dry
Impact on Function
*
No impact
Mild limitation
Moderate limitation
Severe limitation
Additional Comments
Submit Assessment
Should be Empty: