1Before you begin2Wound clinic form Is this a post surgery or a outpatient review? Yes No Was this at Toowoomba Hospital or Other Hospital? Toowoomba Other Hospital This form is not for post surgery or outpatient reviews. Please contact the treating hospital or doctor for post surgery or outpatient review.Is the wound on the foot? Yes No This form is not currently for foot wounds. Please contact the Darling Downs Health Podiatry Service P: 07 4616 6352 or E: ddtwbpod@health.qld.gov.au Practitioner InformationAre you are?* General Practitioner Nurse Practitioner Registered/Enrolled Nurse Name* First Last Provider number Contact NumberEmail (please use generic email address)* Nurse Referral InformationGP 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 requestTreating GP InformationTreating Doctor* First Last Provider number Email* Practice Location InformationPractice/Facility Type* General Practice Nursing Home HHS Practice/Nursing Home Name* Practice/Nursing Home Email Address Street Address Suburb State Postcode HHS InformationPatient URN Facility Facility Care TypeEDNon admittedAdmittedOutpatientPrimary care / communityResidential Aged Care FacilityPatient InformationPatient Name* First Last Patient Sex* Male Female Indeterminate Patient Date of Birth* DD slash MM slash YYYY Patient Contact Number*Patient Address* Street Address Suburb State Postcode Medical InformationFull Medical History*Medication History including allergies*Wound InformationLocation of wound if anatomical features not shown in photos* Duration of WoundPlease enter a number greater than or equal to 1.Unit of TimeHoursDaysWeeksMonthsYearsHiddenCause/Wound Type Haematoma Blister Fistula Surgical Fungating Burn Skin tear Dehisced suture line Ulcer Pressure injury Other Other HiddenPain Score IndicatorsNon verbals demonstrated Anger Guarding Tense Irritability Grimacing Diaphoresis Moaning/crying Restlessness Pain relief prior to dressing* Yes No HiddenPain Score1-10Please enter a number from 1 to 10.Exudate AmountNilLowModerateHeavyLow - light marking Moderate - extensive marking Heavy - wet with strikethrough Exudate TypeSerousHaemoserousPurulentSanguinousIs 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 SizeWound Size*Measure greatest (cm) - Length x Width x Depth Wound PhotosPhotos (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 Select files 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 TreatmentPresent 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
