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WOUND ASSESSMENT FORM

Patient Name (print): __________________________________________ Date of Birth: ___________________ Location of Wound: __________________________________________________________________________________ Type of Wound: _____________________________ Age of wound: _________________months Current Wound Assessment Information: Date of current assessment: ___/___/______

Measurements: _______ cm length x ______cm width x ______cm depth

Exudate Scant Small Moderate Large Copious Type/Color Clear Blood tinged Yellow Tan Purulant Sanuineous Quantity Green Gray Present Absent Foul Musty Pain Wound Bed Red Pink White Gray Black Tan Brown Bloody Pale Sloughing Necrotic Eschar Granular Weeping Healthy Yes or No 1 (Low)­10 (high) Wound Margins Edematous Clean Calloused Intact Macerated Jagged Surrounding Tissue Pink Cool White Blanched Red Shiny Pale Edematous Warm Undermining ____ o'clock to ____ o'clock cm ____ o'clock to ____ o'clock cm Tunneling/Sinus Toward ____ o'clock cm Toward ____ o'clock cm

Color

Tissue

Odor

Concurrent Treatment Measures: Debridement: ___yes ____no Debridement Date: ___/___/_____ Support surface in use: ___yes ___no Turning/repositioning: ___yes ___no Nutritional concerns: ___yes ___no If yes, please explain: ___________________________________ Support Incontinence Control: ___yes ___no If no, please explain: ______________________________ Completed By: ____________________________________ Employed by: _____________________________________ Printed Name: ____________________________________ Date Completed: ____/____/_______ PLEASE FAX COMPLETED FORM TO 757-640-0136.

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