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Wound Care in Naperville, IL by Absolute Integrated Health Centers
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Wound Care Questionnaire
On a Scale of 1-10 how bad do you think your wound or ulcer is?
*
1-3
4-6
7-10
Has your wound/ulcer been able to heal on its own?
Yes
No
Where is your wound/ulcer located? (Check all that apply)
*
Feet/Toes
Legs
Back
Arms
Hands
Other
How often do you get wounds or ulcers?
*
Rarely
Occasionally
Frequently
Always
What best describes your situation? (Check All That Apply)
*
Your Wound or Ulcer Impacts Quality of Life
You Have Trouble Sleeping
Your Wound Opens Frequently
You Change Plans Because of Your Wound/Ulcer
Even on "Good Days" Your Wound or Ulcer Bothers You
Any Other Info You Wish to Provide?
Name
Name
First
First
Last
Last
Phone
*
Email
*
If you are human, leave this field blank.
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