Form for Guided/Evaluated Procedures
Please fill in one form per patient/procedure
Clinic Name
Country
Named Contact Person
Patient Name
Age
Breed
Sex
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Wound Management
Short history and description of wound
Systemic medications before preparation period, start date and duration of use:
Wound treatment before preparation period, start date and duration of use:
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Preparation Period
Preparation period dates
Eg. Planned period 7-9 days before surgery
Systemic medications, start date and duration of use, during preparation period (if any):
Wound treatment during preparation period, start date and duration of use, please list:
Photo of wound before preparation period
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Photo of wound immediately before surgery
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Surgical Procedure
Date of surgery
-
Day
-
Month
Year
Date
Procedure
Reconstructive surgery
Skin graft
Pre-operative medications
Short description of procedure (or copy & paste surgical report)
Photos of procedure
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Immediate post-op photo before bandage/cast
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Please detail the dressing/bandage/cast used immediately post surgery, include dates
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Postoperative Management
Please detail the dressings/bandages/cast used after the initial dressing, include dates of each redress
Follow up photos
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If complications occurred, please give details and management strategy
Photos of complications, if they occurred
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Dates of hospitalisation
Date treatment completed/wound healed/lost to follow up????
-
Day
-
Month
Year
Date
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Final Result
Brief description of cosmetic result
Photo of final appearance
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Owner satisfaction
Brief description of functional result
Limitations in movement
yes
no
If yes, due to
initial wound
scar
N/A
Level of exercise
Pasture
Recreation
Competition
If competition, level compared to before wound
lower level
similar level
higher level
N/A
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Your Experience
Did the procedure go well?
Did you have any setbacks or challenges?
Would you change your management if you had this case again?
What did you learn from this case?
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