Southwest Technologies, Inc

southwest technologies, inc.

WOUND CARE EVALUATION

Clinicians Name:

Facility:

Address:

City: State: Zip:

Phone: Fax:

Attending Clinician Consulting Other:

Products to be evaluated:

Elasto-Gelä Wound Dressing (size used)______Toe-Aid™ Digit Dressing

Gold Dust™ Wound Filler

Stimulen™ Collagen (powder, gel, sheet, lotion) ______

Securing Dressings with:______

Clinician’s Signature: Date:

Physician’s Name: ______

(SWT is in compliance with facility listed above and is approved for product evaluation. )

Note: Complete one (1) form for each patient:

Initial Patient Assessment / Treatment History: Wound Care
Facility: / Initial Wound Assessment
Type: Nursing Home Home Health
Hospital Clinic / Wound Type: check one below. On body parts below; circle area where wound is located.
Patient Information:
Sex: Male Female Age: ______
Height:______inches Weight:______lbs.
Date Admitted:______
Reason for Admission:______
______
______
Date wound noted: ______
Present upon Admission: ____Yes ____No / Pressure Ulcer:
___Stage I, ___Stage II, ___Stage III, ___Stage IV,
______Not able to stage
------
Describe if other than pressure ulcer type of wound: ___Partial Thickness, ___Full Thickness
Details: ______
Patient History:
Immunosuppressed
Glucose out of control
Diminished blood supply
Malodorous due to gangrene
Incontinent (urine) and contaminates
dressing
Explosive diarrhea/contaminates dressing
Edema (increase of interstitial fluid)
Contamination (overcolonization of
bacteria)
Mental instability
Current Medicines:
______
______
______
Other notes patient history:
______
______
______
Form continues on reverse /
Front Back
Wound Size (LxWxD) ______cm
Tunneling: Yes No
Undermining: Yes No
Infected: Yes No
Drainage (Exudate)
none light moderate heavy
Wound Bed, Total=100%
Epithelialization ______%
Granulation ______%
Slough ______%
Necrotic/eschar ______%
Surrounding Tissue
Intact Macerated Erythema other

Record of Wound Healing:

Date:______, Attending Clinician ______, Wound Size (LxWxD)in cm ______

Worst Pain - Severe Pain - Moderate Pain - Mild Pain - No Pain

Comments: ______

Record of Wound Healing:

Date:______, Attending Clinician ______, Wound Size (LxWxD)in cm ______

Worst Pain - Severe Pain - Moderate Pain - Mild Pain - No Pain

Comments: ______

Record of Wound Healing:

Date:______, Attending Clinician ______, Wound Size (LxWxD)in cm ______

Worst Pain - Severe Pain - Moderate Pain - Mild Pain - No Pain

Comments: ______

Physical Status Since Study Initiated: Improved Unchanged Deteriorated

**Notify Southwest Technologies, Inc. if adverse reaction occurs or if you have any questions during wound evaluation: 1-800-247-9951, 1-816-221-2442, email: .

1746 Levee Rd, North Kansas City, MO 64116

Termination of Study: Wound Healed Patient Expired Patient was Discharged

LTCF Home Other

Other Reason:

Conclusion of this Study: After using Elasto-Gelä (bacteriostatic wound dressing), Gold Dust™ (absorbent wound filler) and/or Stimulen™ (collagen products), would these be products you would like to have in your facility? Yes No. Where do you normally purchase products (list of DME or wholesaler)? ______.

Additional comments/suggestions of how SWT can supply these products to your facility: 1)formulary, 2)corporate purchasing or key administration, 3)each branch location has authority to purchase products without formulary.

WC Eval Page 2 of 2

Rev 06-09