Wound Assessment Form Template
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Wound Assessment Form
Please complete this form to evaluate and document the characteristics, severity, and progression of wounds.
Date
Patient Name
Patient ID Number
Assessor Name
Patient Information
Age
Weight (kgs)
Gender
Male
Female
Smoking
Alcohol
Allergies
Diseases
Medications
Wound Type
Duration of Wound
Previous Treatments
Wound Location
Wound Assessment
Tissue Type
Exudate Type
Any Infections
Swab taken:
Wound Edge Assessment
Periwound Tissue Skin Assessment
Treatment Plan
Management Goals
Treatment Choice
Date of Next Visit
Main Objective at Next Visit
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