WCC - New Client Intake Form

The Wound Care Clinics of Arizona

Customer Service

Phone: +1 (480) 625-4704

Client Information

First Name

Last name

Date of Birth

Age

Height

Weight

Gender

Male

Female

Other

Prefer not to say.

Cell Phone Number

Home Phone Number

Email Address

Home Address:

How would you like us to send you appointment reminders? (Check all that apply)

Text Message

Email

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

Emergency Contact Information

Add another emergency contact

Wound Information

Where is your wound?

When did your wound start?

How did your wound start?

Is this a recurring wound?

Mark the areas on the image where you are experiencing symptoms

How is your wound pain relieved?

Medication

Elevation

Dangle

Other

If other please describe.

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.

Alcohol Consumption, Nicotine, and Recreational Drug Use

How many alcoholic drinks to you consume in a week?

None. Dont drink.

1-3

3-5

5-10

10-15

15+

If yes; How many years?

If no: Enter n/a

Are you a smoker or vaper?

Yes

No

If Yes, how much do you smoke or vape.

If yes; How many years?

If no: Enter n/a

Do you use recreational drugs?

Yes

No

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

If yes; How many years?

If no: Enter n/a

Do you live alone?

Yes

No

Do you have someone available to help you?

Yes

No

Family Medical History

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

Asthma

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Autoimmune Disease

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Bleeding Disorder

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Cancer

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Circulation Problems (PVD, PAD)

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Congestive Heart Failure (CHF)

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Coronary Artery Disease (CDF)

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Deep Vein Thrombosis (DVT)

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Dementia

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Depression / Anxiety

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Diabetes

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Emphysema or COPD

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Hepatitis

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

High Blood Pressure (Hypertension)

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

High Cholesterol (Hyperlipidemia)

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

HIV / AIDS

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Kidney Disease (Renal Failure)

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Lymphedema

Self Family Member n/a

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Neuropathy

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Thyroid Disease

Self Family Member No

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

Other Disease

Self Family Member n/a

If self; How many years since first diagnosed?

If No: Enter n/a

If family member; List who and age they were diagnosed.

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

No

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. *If none type none.

Medical History (Continued)

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

Yes

No

Do you take any diuretic or water pills

Yes

No

If yes please list:

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

Yes

No

If yes please list:

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.

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 full name.

First Name

Middle Initial (s)

Last Name

Your information will be encrypted.

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