Wound Care Intake and Assessment Form

Wound Care Intake and Assessment Form — Form Fields

This healthcare template includes 10 fields. Document wound characteristics, history, and patient information for wound care clinic visits. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Contact Email (email, required)
• Referring Physician or Provider (text, optional)
• Wound Type (dropdown selection, required) — options: Diabetic ulcer, Venous ulcer, Pressure injury, Surgical wound, Traumatic wound, Arterial ulcer, Other
• Wound Location on Body (text, required)
• How long has this wound been present? (multiple choice, required) — options: Less than 2 weeks, 2-8 weeks, 2-6 months, Over 6 months
• Current Wound Treatments (checkboxes, optional) — options: Daily dressing changes, Compression therapy, Negative pressure wound therapy, Debridement, Antibiotics, None
• Current dressing type and frequency (long text, optional)
• Relevant Medical Conditions (checkboxes, optional) — options: Diabetes, Peripheral vascular disease, Heart failure, Immunosuppression, Malnutrition, None