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Documentation: Consultation Intake questionnaire

Documentation: Consultation Intake questionnaire

Documentation: Consultation Intake questionnaire


Instructions: Below is a template for Consultation Intake Questionnaire, which can be adapted to fit your needs. A fillable PDF is attached for your convenience. Prior to use, ensure the adapted version is reviewed and approved by responsible parties within the wound care and hyperbaric oxygen therapy clinic/hospital. 

CONSULTATION INTAKE QUESTIONNAIRE


Facility:                                                    

Facility Contact:                                                                    

Intake Date:

Appointment Date:

Patient Name:                                              

Date of Birth:

Primary Insurance:                                        

Secondary Secondary:

Is the patient a DNR?    [ ] Yes     [ ]No

Number of Wounds: 

Wound Location(s):

Are the wounds examined sitting or lying down?

Is the patient: [ ] Ambulatory [ ] Ambulatory w/ assistance [ ] Wheelchair [ ] Stretcher [ ] Total Lift       [ ] Paraplegic        [ ] Quadriplegic

Does the patient have hearing or visual deficits?

Does the patient have a language barrier?

Can the patient complete past medical history and consent for treatment forms?       [ ] Yes       [ ] No

If no, does the patient have a durable power of attorney who can complete the forms upon arrival or prior to arrival?       [ ] Yes      [ ] No

Fax number or mailing address for person responsible for completing forms:

If patient is unable to communicate, who will accompany the patient?

Requested Information from referring office or patient: 

  • Face Sheet
  • H&P
  • Medication List
  • Labs
  • Radiology Reports, including MRI
  • Copy of the DNR
  • Transportation Phone Number
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
Topic 1074 Version