-Pre-Visit Patient Assessment-

PNW Wound Specialist — Pre-Visit Patient Assessment

Please answer as best you can before your first visit. Choose “not sure” when offered, or leave optional questions blank and discuss them with us. A trusted helper may assist; please use the patient’s own answers when possible.The sections follow our clinical record order. After submitting, you will continue to the separate PHQ-9. This form is not monitored continuously. Call 911 for a medical emergency. For help completing it, call 509-209-9033.
Patient Full name
Patient Date of Birth.
- Have you ever been told you carry a drug-resistant germ or another infection that may spread to others?
- Please identify the organism or infection, if known:
- Marital status
- How do you usually move around or arrive for care? (Patient Arrival)
  Choose your usual mobility aid. Tell us if you use a manual wheelchair or need transfer assistance.
- Where do you currently live? (Living Arrangement)
  Choose the closest option; we can discuss another arrangement.
- Does someone regularly help you with your care? (Care Provider)
- What is your employment status?
- Does today's medical issue interfere with work or school?
- What is your tobacco use status?
- What is the primary method you consume tobacco?
- About how much tobacco or nicotine do you use per day?
  Include the product and amount, such as cigarettes per day or vaping frequency.
- Start Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yeartobacco use
- Stop Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yeartobacco use
- How often do you have a drink containing alcohol?
- How many standard drinks containing alcohol do you have on a typical day?
- How often do you have 6 or more drinks on 1 occasion?
- Prescription Drugs for Non-Medical Reasons
  In the past year, have you used the following:
- Illegal Drugs
  In the past year, have you used the following:
- How hard is it to pay for basics such as food, housing, medical care, and utilities? (Financial Resource Strain)
  Choose the answer that best describes your current situation.
- We worried whether our food would run out before we got money to buy more.
  For each of the following statements about your food situation please tell me whether the statment was often true, sometimes true, or never true for your household in the last 12 months::
- The food that we bought just didn't last, and we didn't have money to get more.
  For each of the following statements about your food situation please tell me whether the statment was often true, sometimes true, or never true for your household in the last 12 months::
- What is the highest grade or level of school you have completed or the highest degree you have received?
- Do you feel stress- tense, restless, nervous, or anxious, or unable to sleep at night because your mind is troubled all the time - these days?
- Little interest or pleasure in doing things?
- Feeling down, depressed, or hopeless?
- Select current symptoms and conditions a clinician has told you that you have. You do not need to diagnose yourself. In each section, choose all that apply OR “None of these”; do not choose both. If unsure, leave the section blank and discuss it at your visit.
  
  These answers help the care team review your history; they are not a substitute for an examination. Call 911 for new severe chest pain, severe trouble breathing, uncontrolled bleeding, or another medical emergency.
- General symptoms (Constitutional)
- Eyes and vision
- Ears, nose, mouth, and throat
- Heart and circulation (Cardiovascular)
- Breathing and lungs (Respiratory)
- Stomach and digestion (Gastrointestinal)
- Urinary and reproductive system (Genitourinary)
- Muscles, bones, and joints (Musculoskeletal)
- Skin and breast (Integumentary)
- Nerves, sensation, and movement (Neurological)
- Mood, anxiety, and sleep (Psychiatric)
- Hormones and blood sugar (Endocrine)
- Blood, bleeding, and lymph nodes (Hematologic/Lymphatic)
- Allergies and immune system (Allergic/Immunologic)
- BRADEN SCALE
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction & shear
- PHQ-9
  
  Patient Health Questionnaire 9
- 1. Little interest or pleasure in doing things
- 2. Feeling down, depressed, or hopeless
- 3. Trouble falling or staying asleep, or sleeping too much
- 4. Feeling tired or having little energy
- 5. Poor appetite or overeating
- 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
- 7. Trouble concentrating on things, such as reading the newspaper or watching television
- 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
- 9. Thoughts that you would be better off dead or of hurting yourself in some way
- If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
- Nutrition history
  
  Tell us about food intake, weight change, and mobility. These answers help your care team review nutrition; they do not produce a validated nutrition-screen score.
- Has your food intake decreased during the past 3 months?
- Have you lost weight during the past 3 months?
- Which best describes your usual mobility?
- Have you had a major illness or significant emotional stress during the past 3 months?
- Neuropsych problems
- “Fall in past 6 months?”
- What is the problem's status?
- How is it affecting your function?
- How long have you had pain related to this wound?
  Leave blank if you have no wound pain or are unsure. We will confirm the duration at your visit.
- Is this problem likely self-limited?
- How strong is your wound pain right now?
  0 = no pain; 10 = worst pain you can imagine.
- Have you noticed or been told there may be an infection in this wound?
  Examples include increasing redness, warmth, swelling, pus, fever, or worsening pain. The clinician will assess this; you do not need to diagnose it.
- Is it limb threatening?
- How often do you have wound pain?
  Continuous = all the time; intermittent = comes and goes; occasional = now and then.
- How did it start?
- What factors contribute to poor healing?
- Has this wound been treated before, or has it returned?
  If neither option fits, leave blank and discuss it at your visit.
- What additional factors impact or complicate the situation?
- What other symptoms have you had?
- What matters most to you about your wound care? (Goals)
  For example: less pain, walking more easily, fewer dressing changes, or returning to an activity.
- Name of person completing this form (if different from the patient)
- Signature (optional)
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PNW Wound Specialist — Pre-Visit Patient Assessment

BRADEN SCALE

PHQ-9

Nutrition history