Name

DOB

Address

Phone

NOK name/ contact details

Medicare Card number

Reference Number

Exp

DVA Number: (If applicable)

NDIS

Yes No

NDIA-managed

Yes No

Plan-managed

Yes No

Self-managed

Yes No

GP/ Dr details

Clinic

Address

Phone

List any other clinicians involved in wound care (Specialists, Surgeons, Allied Health, Carer Agency, Wound Clinics)

Medical History (or attach GP health summary)

Current Medications

Reason for referral (outline of problem / presenting issues / specific requests to be addressed)

Summary of previous wounds and treatments

Allergies

Palliative Care

Yes No

Results of investigations (swab, biopsy, blood tests, scans, ultrasounds, x-rays, MRI, angiography) Attach results.

Location and type of wound

Other

Surrounding Skin: Inflamed (heat/redness/swelling)

Friable Macerated Dry

Length

Depth

Width

Wound Colour

Pink Yellow Black Green

Odour

Yes No

Pain

During procedure Intermittent Constant

Exudate Type

Serous Serosanguineous Purulent Sanguineou

Exudate Amount

Heavy Light Moderate None

Tissue

Epithelial (Pink or pearly White) Granulating (Red and moist) Slough (yellow, brown or grey) Necrotic (Hard, dry and black) Hyper granulating (Red, uneven or granular)

Surrounding edges

Infection

Yes No

Current Cleansing Agent

Current Primary Dressing

Secondary Dressing

Bandaging/retention dressing

Current Frequency

Additional

I have attached the patient's medical history and medication chart

Yes No

If Yes, attach patient's medical history and medication chart

I have sent clear current color photos of the wound with the patient's details.

Yes No

If Yes, attach clear current color photos of the wound with the patient's details

Do you consent for de-identified clinical photographs to be used for research, education and training purposes? (Please check with the patient or patient's next of kin before answering)

Yes No

Referring Person Signature

Print Name

Clinical Managers Name

Phone

Wound Care Referral Form