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Online Wound Assessment

Are you concerned about a wound that won't heal?

Some wounds just won’t heal with time.  These wounds require medical treatment that goes beyond a simple dressing.  Take our online wound assessment now to see if you are at risk for a non-healing wound.    

Please check the box next to all of the statements that apply to you.

I have a wound that has not healed in four weeks.
I have a wound that is reoccurring.  (It heals for a few weeks or months, but then returns)
I have been told that I may need an amputation due to my wound.
   
  The following are risk factors for delayed healing.  Please check all that apply to you.
   
 
Diabetes
Vascular disease
Limited mobility
Autoimmune diseases such as rheumatoid arthritis and scleroderma
Use of drugs that delay healing such as steroids and chemotherapy
High cholesterol
Obesity
Smoking
Alcohol use
Poor nutrition
 

The following are common physical features of various wound types.  Please check all that apply to you.
   
 
An open wound or sore that has not healed in four weeks
Drainage
Discoloration on lower legs
Blisters and swelling on lower legs
   

After completing the form above, please fill in your contact information and press submit.  A nurse from the Wound Healing Center will review your assessment form and be in touch to discuss a possible evaluation with a wound healing physician.  Or if you prefer, you can contact us directly at (217) 326-4325.        

Information in red is required.

First Name

Last Name

Email

Address/PO Box

City

State

Zip

Phone Number

Birth Date
   

Have you been seen at Carle Foundation Hospital or Carle Clinic Association before?  Yes  No

 

 
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Carle Clinic Association and Carle Foundation Hospital are separate business corporations that work together to provide quality care and services to their patients. Carle Clinic Association and Carle Foundation Hospital contract with insurance providers separately and may or may not choose to participate in all of the same insurance plans. Patients are urged to check with their carriers as to whether services are covered for either or both organizations. Copyright © 2004, 2003, 2002 Carle Clinic Association and Carle Foundation Hospital.
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