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Introduction

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Patient Name: Date of Evaluation:
Location:
Type:
Measurements (Length x Width x Depth):
Wound Base:
Signs/Symptoms of Infection (Yes/No):
Girth Measures:
Sensation:
Peripheral Pulses:
Other Tests (TCP02, Vascular Studies, X-Rays, Labs, etc.):
Consultations (MD, Rehab, Social Services, Home Health, Diabetes Education, etc.):

Treatment Plan (include plan, DME, home dressing supplies):

1.

2.

3.

4.

5.

6.

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