Wound Care Clinic Follow-Up Assessment

Wound Care Clinic Follow-Up Assessment — Form Fields

This healthcare template includes 15 fields. Follow-up assessment form for patients receiving ongoing wound care treatment. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Patient ID (text, required)
• Date of Visit (text, required)
• Wound Location (text, required)
• Wound Length (cm) (number, required)
• Wound Width (cm) (number, required)
• Wound Depth (cm) (number, optional)
• Wound Type (dropdown selection, required) — options: Pressure Ulcer, Diabetic Ulcer, Venous Ulcer, Surgical Wound, Burn, Traumatic, Arterial Ulcer
• Wound Stage/Grade (dropdown selection, required) — options: Stage 1, Stage 2, Stage 3, Stage 4, Unstageable, Deep Tissue Injury
• Wound Bed Appearance (dropdown selection, required) — options: Granulation (red), Slough (yellow), Eschar (black), Mixed, Epithelializing (pink)
• Exudate Amount (dropdown selection, required) — options: None, Scant, Moderate, Heavy
• Exudate Type (dropdown selection, optional) — options: Serous (clear), Sanguineous (bloody), Purulent (pus), Serosanguineous
• Signs of Infection (multiple choice, required) — options: Yes, No
• Treatment Applied (checkboxes, required) — options: Wound Cleansing, Debridement, Negative Pressure, Compression, Topical Medication, Dressing Change, Skin Graft Assessment
• Treatment Notes and Plan (long text, required)