Wound care

HTS Wound Care - Patient Intake Form and Checklist

Patient Information:

First Name*

Last Name*

Email

Date of Birth*

Primary Care Provider Information:

First Name*

Last Name*

You should be required to enter at least Email or Phone number*:

Phone number

Email

Facility Information:

Name*

Address*

Phone number*

Referring Information:

Name*

Email*

Phone number*

Documents:

Patient Face Sheet, including demographic information (first name, last name, date of birth, etc)*

Patient insurance information, including copies of their insurance cards (front and back of each)*

Recent primary care provider and/or specialists progress notes from within the past 1-2 months*

Patient medical history*

Patient medication list*

Patient allergy list*

Pertinent wound care notes from the past 30 days, if available

Add file(s)*

Wound-Specific Information Form

Wound #1:

Wound Location: (e.g., sacrum, left heel, etc)*

Wound Type/Etiology: (Pressure Ulcer, Diabetic Ulcer, Venous Ulcer, Arterial Ulcer, Skin Tear, Surgical Wound, Burn, Unknown, Other)*

Wound length, cm*

Wound width, cm*

Wound depth, cm*

This wound has been present for at least 30 days*

Yes

No

This wound has not healed >50% over the past 30 days*

Yes

No

What stage is this wound?*

List any and all wound therapies that have been performed on this wound over the past 30 days. If no therapies were performed, write none*

0 / 250

Additional Notes:*