Darling Downs Health Test

Practitioner Information

Are you are?*

General Practitioner
Nurse Practitioner
Registered/Enrolled Nurse

Name*

First Last

Provider number

Contact Number

Email (please use generic email address)*

Nurse Referral Information

GP or Treating doctor is required to be aware and agreeable of this request. You will not be able to proceed further otherwise.

Consent from Treating GP and Details*

GP or treating Doctor is aware and agreeable to this request

Treating GP Information

Treating Doctor*

First Last

Provider number

Email*

Practice Location Information

Practice/Facility Type*

General Practice
Nursing Home
HHS

Practice/Nursing Home Name*

Practice/Nursing Home Email

Address

Street Address Suburb State Postcode

HHS Information

Patient URN

Facility

Facility Care Type

Patient Information

Patient Name*

First Last

Patient Sex*

Male
Female
Indeterminate

Patient Date of Birth*

Patient Contact Number*

Patient Address*

Street Address Suburb State Postcode

Medical Information

Full Medical History*

Medication History including allergies*

Wound Information

Location of wound if anatomical features not shown in photos*

Duration of Wound

Please enter a number greater than or equal to 1.

Unit of Time

Hidden

Cause/Wound Type

Other

Hidden

Pain Score Indicators

Non verbals demonstrated

Anger
Guarding
Tense
Irritability
Grimacing
Diaphoresis
Moaning/crying
Restlessness

Pain relief prior to dressing*

Yes
No

Hidden

Pain Score

1-10

Please enter a number from 1 to 10.

Exudate Amount

Low - light marking Moderate - extensive marking Heavy - wet with strikethrough

Exudate Type

Is the wound below the knee?*

Yes
No

Please note: Since the wound is below the knee we must receive at least one photo showing the leg from the foot to the knee.

Is there pedal pulse present?*

Yes
No

Is pedal pulse?*

Strong
Weak

Wound Size

Wound Size*

Measure greatest (cm) - Length x Width x Depth

Wound Photos

Photos (8MB maximum file size. If uploading multiple photos, make sure that file names are different)

When taking photos of wound please include ruler as reference if you have not included size of wound above. For more detailed instructions or to print out a paper ruler click on the following link: (link to page/site with instructions)

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, docx, Max. file size: 40 MB.

Reminder: Since the wound is below the knee we must receive at least one photo showing the leg from the foot to the knee.

Wound Treatment

Present and previous treatment utilised?*

Are there any dressing or tape allergies?*

Yes
No

What are they?

Is bandaging or compression stockings being utilised?*

Yes
No

What type?

Stocking
Bandage
Tubular

Consent*

I can confirm that I have obtained patient consent (or substitute decision maker) for this service and any photos attached. I have also, advised the patient that a medical record will be created for them at the Toowoomba Hospital if one currently does not exist.

Security

Toowoomba Wound Clinic Form

Practitioner Information

Nurse Referral Information

Treating GP Information

Practice Location Information

HHS Information

Patient Information

Medical Information

Wound Information

Wound Size

Wound Photos

Wound Treatment