WCC - New Client Intake Form - The Wound Care Clinics of Arizona

Customer Service

Phone: +1 (480) 625-4704

Client Information

First Name

Last name

Home Phone Number

Cell Phone Number

Email Address

Date of Birth

Age

Gender

Male

Female

Other

Prefer not to say.

Height

Weight

How did you hear about us?

Primary Care Doctor

Google

Facebook

Apple Maps

Other

General Information

Primary Care Physician Name:

Primary Care Physician Phone:

Referring Physician Name:

Referring Physician Phone:

Home Health Company Name:

Home Health Company Phone:

Care Facility Name:

Care Facility Phone:

Pharmacy Name:

Pharmacy Address / Cross Streets

Pharmacy Phone Number

Wound Information

Where is your wound?

When did your wound start?

How did your wound start?

Is this a recurring wound?

Physicians that have cared for your wound?

Types of dressings used?

List all surgical or other invasive proceures by type and year.

Example: Double Hip Replaccement - 2008.

How many alcoholic drinks to you consume in a week?

None. Dont drink.

1-3

3-5

5-10

10-15

15+

Are you a smoker or vaper?

Yes

If Yes, how much do you smoke or vape.

Do you use recreational drugs?

Yes

If yes please describe which drugs you use and how often.

Do you live alone?

Yes

Do you have someone available to help you?

Yes

Wound Pain

Is your wound painful?

Yes

What is your current pain level (0-10)?

How would you describe your pain?

Burning

Stabbing

Throbbing

Other

If other please describe.

How is your wound pain relieved?

Medication

Elevation

Dangle

Other

If other please describe.

Family Medical History

Please indicate if you or any of your family members have been diagnosed with the following conditions:

Asthma

Self Family Member

Explain (Who & Age)

Autoimmune Disease

Self Family Member

Explain (Who & Age)

Bleeding Disorder

Self Family Member

Explain (Who & Age)

Cancer

Self Family Member

Explain (Who & Age)

Circulation Problems (PVD, PAD)

Self Family Member

Explain (Who & Age)

Congestive Heart Failure (CHF)

Self Family Member

Explain (Who & Age)

Coronary Artery Disease (CDF)

Self Family Member

Explain (Who & Age)

Deep Vein Thrombosis (DVT)

Self Family Member

Explain (Who & Age)

Dementia

Self Family Member

Explain (Who & Age)

Depression / Anxiety

Self Family Member

Explain (Who & Age)

Diabetes

Self Family Member

Explain (Who & Age)

Emphysema or COPD

Self Family Member

Explain (Who & Age)

Hepatitis

Self Family Member

Explain (Who & Age)

High Blood Pressure (Hypertension)

Self Family Member

Explain (Who & Age)

High Cholesterol (Hyperlipidemia)

Self Family Member n/a

If self; Year of diagnosis.

HIV / AIDS

Self Family Member n/a

If self; Year of diagnosis.

Kidney Disease (Renal Failure)

Self Family Member n/a

If self; Year of diagnosis.

Lymphedema

Self Family Member n/a

If self; Year of diagnosis.

Neuropathy

Self Family Member n/a

If self; Year of diagnosis.

Thyroid Disease

Self Family Member n/a

If self; Year of diagnosis.

Other Disease

Self Family Member n/a

If self; Year of diagnosis.

Medical History

Have you been treated by a doctor in the last 12 months?

Yes No

If yes, please describe.

Date of your last physical exam

Is there a chance that you are pregnant?

Yes No

Do you have any food or medication allergies?

Yes

If yes to allergies to food or medications, please explain.

Medications (Prescription and Over The Counter)

Please list everything you are taking including the strength and frequency for treatment of what disease.

Prescription Medications

Include Strength, Frequency and Condition Being Treated

Over The Counter Drugs

Include Strength, Frequency and Condition Being Treated (Enter none if none)

Vitamins & Supplements

Include Strength, Frequency and Condition Being Treated

Medical History (Continued)

Do you take digoxin (Lanoxin) for a heart problem?

Yes

Do you take any diuretic or water pills

Yes

If yes please list:

Do you take any steroids, i.e. Prednisone?

Yes

If yes please list:

List any other medical conditions not listed above.

List all surgical procedures you have had with approximate dates.

is there anything else you would like to tell the physician? If so please explain.

Emergency Contact Information

Add another emergency contact

Step 1. Check the box below.

By checking this box and typing my name below, I am electronically signing this form.

Step 2. Type in your name.

First Name

Middle Initial (s)

Last Name

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