Wound Assessment Form

Wound Description

    Left or Right side, front or back, sup/inferior

    Location(s)

    Wounding Event

    Wound Size (L*W*D in cm)

    Edema

    YesNo

    Erythema

    YesNo

    Eschar

    YesNo

    Exudate

    Granulation

    YesNo

    Contamination

    YesNo

    Cellulitis

    YesNo

    Maceration

    YesNo

    Odor

    YesNo

    Slough

    Epibole

    YesNo

    Tunneling

    YesNo

    Undermining

    YesNo

    Stage (for decubitus ulcers)

    Ulcer Description

    Wagner scale for diabetic ulcers

    [select Scale '0" "I" "II" "III" "IV" "V"]

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