HTS Wound Care - Patient Intake Form and Checklist

Patient Information:

Primary Care Provider Information:

Facility Information:

Referring Information:

Patient location:

Medical history:

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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*
At least one photo of each wound*
If any wound is below the knee, please obtain an Ankle Brachial Index (ABI):

Wound-Specific Information Form

Wound #1:

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