Freedom Health & Wellness - Wound Care (Google)

1

WHAT IS YOUR MAIN CONCERN?* This field is required.SELECT ONE

ARTERIAL WOUNDS

VENOUS LEG ULCER

DIABETIC FOOT ULCER

SACRAL ULCERS

PRESSURE ULCERS

BURNS

SURGICAL WOUNDS

SOMETHING ELSE

2

HOW LONG AGO DID THIS HAPPEN?* This field is required.SELECT ONE

TODAY

1-7 DAYS AGO

1-4 WEEKS AGO

1+ MONTH AGO

3

Do you use any of the following to move around your home or leave your home?* This field is required.Select all that apply

Cane

Walker

Wheelchair

Scooter

Require assistance from another person

No assistance needed

4

Can you leave your home safely and independently without help from a person or a device?* This field is required.Select One

Yes

No

5

Do you have any medical conditions that make it unsafe or medically inadvisable for you to leave your home?* This field is required.Please Specify The Condition if Yes

6

When you do leave your home, do you need:Select One

Someone to accompany you

Special transportation (e.g., wheelchair van)

Physical help to walk or transfer

No assistance

7

DO YOU HAVE A MEDICARE POLICY?* This field is required.SELECT ONE

YES

NO

8

WHAT IS YOUR NAME?* This field is required.ENTER FIRST & LAST NAME

First Name

Last Name

9

WHAT IS YOUR EMAIL ADDRESS?* This field is required.ENTER EMAIL ADDRESS

example@example.com

10

Terms and Conditions* This field is required.

11

WHAT IS YOUR PHONE NUMBER?* This field is required.ENTER PHONE NUMBER

12

Sender