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