Wound Care Patient Intake Form Template

The intake form is the first clinical document in every patient's wound care record, and in mobile wound care, it's frequently the last chance to collect information before a clinician is standing in a patient's living room or at a SNF bedside without the data they need. A missing insurance ID means a claim that can't be submitted. A missing wound onset date means medical necessity documentation that starts with a gap. A missing medication list means a care plan built without knowing the patient is on anticoagulants or immunosuppressants that directly affect wound healing.

Generic patient intake forms don't work for wound care. They collect demographics and insurance --- necessary but insufficient. Wound care intake requires wound-specific clinical history, vascular screening questions, comorbidity data that drives healing prognosis, and referral source information that feeds both care coordination and practice growth tracking.

This template covers every field category a wound care intake form should include, with the rationale for why each field matters clinically, operationally, or for billing. For building the referral pipeline that feeds these intake forms, see Wound Care Referral Strategy.

Section 1: Patient Demographics

Standard demographic fields with wound-care-specific additions:

Full legal name (as it appears on insurance card)
Date of birth
Preferred contact phone number and type (mobile, home, facility)
Address (home address for home health patients; facility name, unit, and room number for SNF/ALF patients)
Emergency contact (name, relationship, phone)
Referring provider (name, NPI, practice, phone, fax) --- critical for care coordination and for tracking referral sources
Primary care provider (name, NPI, practice, phone, fax) --- may differ from referring provider
Preferred pharmacy (name, phone, fax) --- for topical prescriptions and oral antibiotics

Why referring provider matters beyond coordination: Many payers require a referral or order from a physician for wound care services. If the intake form doesn't capture the referring provider's information including NPI, the first claim may be denied for lack of a qualifying referral. Capture it at intake, not after the first visit.

Section 2: Insurance and Authorization

Insurance verification fields need to be more granular for wound care than for primary care because wound care involves procedure codes, product codes, and durable medical equipment that each have different coverage rules.

Primary insurance (payer name, plan type, member ID, group number)
Secondary insurance (same fields)
Medicare Beneficiary Identifier (MBI) if Medicare --- separate field with format validation (11 characters, alphanumeric)
Medicare Advantage plan name (if applicable --- critical because MA plans have different prior auth requirements than original Medicare)
Workers' compensation claim number (if wound is work-related --- separate billing workflow)
Authorization status for wound care services (authorized / pending / not required)
Prior authorization number (if already obtained by referring provider)
Patient's consent to verify benefits (signature and date)

Key field: Medicare vs. Medicare Advantage. This single distinction changes the entire billing workflow. Original Medicare follows LCD medical necessity criteria and does not require prior authorization for most wound care procedures. Medicare Advantage plans often require prior auth for skin substitutes, NPWT, and sometimes routine debridement. Capturing the plan type at intake prevents authorization-related denials on the first claim.

Section 3: Wound History

This section captures the clinical information that drives both the care plan and the medical necessity documentation from day one.

Number of active wounds
For each wound:
- Anatomical location (use body diagram if possible)
- Wound etiology (diabetic foot ulcer, venous leg ulcer, pressure injury, surgical, traumatic, arterial, mixed, other)
- Wound onset date (approximate if exact date unknown --- document "patient reports wound present since approximately [date]")
- How the wound started (patient's account)
- Previous treatments tried and duration (standard dressings, antibiotics, debridement, skin substitutes, NPWT, hyperbaric oxygen)
- Previous providers who treated the wound
- Whether the wound has been previously healed and recurred
- Current dressing being used (what the patient or facility is applying now)
- Date of last dressing change

Why wound onset date is critical: Medicare LCDs for skin substitutes typically require documentation that the wound has failed to respond to at least 4 weeks of standard wound care. If the onset date is unknown or undocumented, you cannot demonstrate the required treatment duration. A patient-reported approximate date documented at intake is significantly better than no date at all.

Section 4: Vascular Status Screening

Vascular insufficiency directly impacts wound healing and determines eligibility for certain interventions. Capturing vascular screening data at intake prevents delays in treatment planning.

History of peripheral arterial disease (PAD)
History of deep vein thrombosis (DVT) or chronic venous insufficiency (CVI)
Previous vascular surgeries or interventions (bypass, stent, angioplasty)
Most recent ABI (ankle-brachial index) result and date (if available)
Most recent arterial or venous duplex study and date (if available)
Current use of compression therapy (type, compliance)
Pedal pulses (to be assessed at first clinical visit --- note on intake whether patient can palpate their own pulses, which is screening, not diagnostic)

Why this matters at intake: A patient referred for a non-healing diabetic foot ulcer who has an undocumented ABI of 0.5 has critical arterial insufficiency that makes debridement risky and skin substitute application likely to fail. Identifying this at intake --- or flagging the absence of vascular data --- lets the clinician order appropriate studies before the first treatment visit rather than discovering the issue after three failed treatments.

Section 5: Comorbidity and Medication Screening

Wound healing is systemic. The intake form needs to capture the conditions and medications that directly affect healing trajectory and treatment decisions.

Comorbidities (check all that apply):

Diabetes mellitus (Type 1 / Type 2) --- most recent HbA1c and date
Peripheral neuropathy
Renal disease / dialysis
Heart failure
COPD / respiratory disease
Malnutrition / unintentional weight loss
Obesity (BMI > 30)
Immunosuppression (disease or medication-related)
Active cancer or recent chemotherapy/radiation
Tobacco use (current, former, never --- pack-year history if applicable)
Alcohol use
Cognitive impairment / dementia (affects ability to participate in wound care)

Current medications (specifically flag):

Anticoagulants (warfarin, DOACs, aspirin) --- affects debridement bleeding risk
Immunosuppressants (steroids, methotrexate, biologics) --- delays healing
Insulin and oral hypoglycemics --- glycemic control affects healing
Antibiotics (current, recently completed) --- affects wound culture results
Vasopressors --- peripheral perfusion impact

Allergies: Latex, adhesive tape, iodine, silver, sulfa, specific dressing materials. Adhesive allergies are particularly important in wound care --- a patient allergic to acrylate adhesives cannot use most bordered dressings.

Section 6: Functional and Social Assessment

For mobile wound care patients, functional status and social support determine whether the care plan is actually achievable between visits.

Ambulatory status (independent, assistive device, wheelchair, bed-bound)
Living situation (alone, with family/caregiver, assisted living, skilled nursing facility)
Primary caregiver (name, relationship, availability for dressing changes)
Caregiver's ability to perform dressing changes (willing and able, willing but needs training, unable)
Access to supplies (can obtain dressings independently, needs delivery, facility provides)
Home environment concerns (stairs, cleanliness, pets, hoarding, safety)
Transportation (ability to attend follow-up appointments or vascular studies if needed)

Section 7: Consent and Acknowledgments

Consent to treat (general wound care services including debridement, dressing application, wound measurement and photography)
Photography consent (wound photographs for clinical documentation --- specify that photos are part of the medical record and subject to HIPAA protections)
Telehealth consent (if practice uses telehealth for follow-up or triage)
Financial responsibility acknowledgment (patient understands they may be responsible for copays, deductibles, and non-covered services)
Assignment of benefits (authorization for insurance payments to be made directly to the practice)
Notice of Privacy Practices (HIPAA acknowledgment --- patient received and reviewed)
Patient signature and date

Practical Implementation Notes

Digital vs. paper. If your practice uses an EHR, build the intake form as a structured template within the system so that data flows directly into the clinical record. A paper intake form that gets scanned as a PDF but never entered into structured fields creates a documentation island --- the data exists but isn't queryable, reportable, or available in the clinical workflow without opening the scanned document.

Pre-visit vs. point-of-care. For patients referred from physician offices or facilities, send the intake form to the referral source with the referral acknowledgment. Getting intake data before the first visit lets the clinician arrive prepared with appropriate supplies, prior authorization in progress, and vascular studies ordered if the screening section reveals gaps.

Annual updates. Insurance changes, comorbidity status changes, and medication changes happen between visits. Build an abbreviated re-intake form for annual updates that captures changes without repeating the entire initial intake.