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JUVEN WOUND ASSESSMENT FORM

®

Date: ____________________________________________ Facility: _________________________________________________________ Contact Name and Title: ____________________________________________________________________________________________ 1. Wound(s): Location, stage, age of wound: _________________________________________________________________________________ Location, stage, age of wound: _________________________________________________________________________________ 2. Primary medical diagnosis: ____________________________________________________________________________________ 3. Vascular status: ______________________________________________________________________________________________ 4. Patient age: _________________________________________________________________________________________________ 5. Wound care regimen (prior to initiating JUVEN) Nutritional supplements: _______________________________________________________________________________________ Treatment protocol: ___________________________________________________________________________________________ Medications: _________________________________________________________________________________________________ Oral Tube fed 6. Current dietary intake (check one) Intake/24 h: Calories: ________________________ Protein: _____________________________________________________ 7. Date JUVEN was initiated: _____________________________________________________________________________________ 8. Did dietary intake change once JUVEN was initiated? No If Yes, how? ____________________________________________________________________________________ WOUND LOCATION: Baseline Measurement Date: ___________ Measurement Week 2 Date: ___________ Measurement Week 3 Date: ___________ Measurement Week 4 Date: ___________

Patient weight Wound measurement (cm) Prealbumin (optional) Albumin (optional) JUVEN intake 2 pks/day

Y/N Baseline Measurement Date: ___________ Measurement Week 2 Date: ___________ Measurement Week 3 Date: ___________ Measurement Week 4 Date: ___________

ADDITIONAL WOUND LOCATION:

Patient weight Wound measurement (cm) Prealbumin (optional) Albumin (optional) JUVEN intake 2 pks/day

Y/N

COMMENTS: ____________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Use JUVEN under medical supervision and as part of a complete, balanced diet.

© 2006 Abbott Laboratories 68421-003/SEPTEMBER 2006 LITHO IN USA

Rebuilding Muscles. Rebuilding Lives.TM

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Wound Assessment Form

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