Wound Assessment Form

Clinic & Registration

Health Clinic

Registration Number

Date of Assessment

Patient Personal Information

Name

IC / Passport

Age (years)

Gender

Ethnicity

Occupation

Phone Number

Address

Presenting Problem & Histories

Current Problem / Chief Complaint

Patient History & Risk Factors

Diabetes Obesity Hypertension Autoimmune disease Smoker Cancer / malignancy Peripheral vascular disease / venous insufficiency

Other risk factors

Drug History & Drug Allergies

Social History

Physical Examination – Vital Signs & Bedside Parameters

Blood Pressure (mmHg)

Pulse (beats/min)

Respiratory Rate (breaths/min)

Temperature (°C)

Pain Score (0–10)

ABSI (if applicable)

Weight (kg)

Height (cm)

BMI

Click "Calculate BMI" to update.

SpO₂ (%)

RBS (mmol/L)

Other findings

Wound Location & Number of Wounds

Overall description of wound locations

Number of wounds

Please describe specific location for each wound (if applicable).

Wound	Wound 1	Wound 2	Wound 3	Wound 4	Wound 5
Location

Detailed measurements per wound are captured below (length, width, depth and TIME assessment).

Wound Measurements

Parameter	Wound 1	Wound 2	Wound 3	Wound 4	Wound 5
Length (cm)
Width (cm)
Depth (cm)

TIME Wound Bed Assessment (per wound)

Summarise TIME for each wound (Tissue, Infection/Inflammation, Moisture, Edges). You can write brief phrases; these will appear in the narrative.

Component	Wound 1	Wound 2	Wound 3	Wound 4	Wound 5
T – Tissue viability e.g. 40% slough, 60% granulation
I – Infection / Inflammation e.g. no signs of infection, mild erythema
M – Moisture balance e.g. minimal serous exudate
E – Edges / Epidermal margin e.g. intact edges, no maceration
Wound type (1–8) / description
Periwound skin classification (Harikrishna) 0-Normal, 1-Fibrous/tissue at risk, 2a-Desiccation, 2b-Maceration, 2c-Allergy, 3-Inflammation without infection, 4-Inflammation with infection, 5-Atypical

Laboratory / Radiology Investigations

Blood investigations (type / date / result)

X-ray / Imaging (type / date / result)

Wound / tissue culture (type / date / result)

Diagnosis – Wound Aetiology

Wound Management Plan

1. Cleansing Solution

Non-antiseptic solution

Antiseptic solution

Antimicrobial solution

2. Primary Dressing

Hydrogel

Collagen

Antimicrobial gel

Hydrocolloid

Alginate gel

Multifunction dressing

Silver

Iodine

Honey

Others

3. Secondary Dressing

Tulle dressing

Multifunction dressing

Film dressing

Foam

Calcium alginate

Gauze / gamgee

Others

4. Skin Protection / Barrier

Aqueous cream

Barrier spray

Zinc oxide

Collagen lotion

Others

5. Odour Management

Odour management (e.g. charcoal)

6. Compression Therapy

Compression therapy

Health Education & Referrals

7. Health Education Provided

General wound care Pressure injury prevention Burn wound care Post-surgical wound care (e.g. circumcision, episiotomy) Control of underlying disease Diabetic wound and diabetic foot care Lifestyle modification (diet, smoking cessation, physical activity, mental health)

Other health education

8. Referral

Other referral

9. Notes

Clinical notes / comments

10. Next Appointment

Next appointment date

Appointment details / plan

Name / Stamp of staff

Designation

Wound Assessment Form

1. Cleansing Solution

2. Primary Dressing

3. Secondary Dressing

4. Skin Protection / Barrier

5. Odour Management

6. Compression Therapy

7. Health Education Provided

8. Referral

9. Notes

10. Next Appointment

Generated Documentation (copy and paste into your clinical notes)