Genadyne XLR8 NPWT Trial Evaluation Form Patient History: Location of Wound: ___________________________________________ Type of Pressure Ulcer Trauma Surgical Partial Thickness Burn ⃝ ⃝ ⃝ ⃝ Dehisced Diabetic Venous Ulceration Flap or Graft ⃝ ⃝ ⃝ ⃝ Other _____________________________ ⃝ Has patient been on a NPWT product in last 30 days? Yes No ⃝ ⃝ Have there been any medical conditions in last 30 days that may impede the progression of wound healing? Yes No ⃝ ⃝ If yes, please indicate: Co-Morbities Medications ⃝ ⃝ Infections Nutritional Status ⃝ ⃝ Other:_______________________________ ⃝ Evaluation Parameters: ______________________________________________ Treatment Facility: (Name) (Location) Dates: _______________________________________________________________ (Start) (End) Therapy Provided @ No Charge: ___________________ At the end of the pre-determined evaluation period, established rental rates will apply. (Signature/Date) Evaluator: __________________________________________________________________
Genadyne XLR8 NPWT Trial Evaluation Form Patient History: Location of Wound: ___________________________________________ Type of ⃝ Pressure Ulcer ⃝ Trauma ⃝ Surgical ⃝ Partial Thickness Burn ⃝ Dehisced ⃝ Diabetic ⃝ Venous Ulceration ⃝ Flap or Graft ⃝ Other _____________________________ Has patient been on a NPWT product in last 30 days? ⃝ Yes ⃝ No Have there been any medical conditions in last 30 days that may impede the progression of wound healing? ⃝ Yes ⃝ No If yes, please indicate: ⃝ Co-Morbities ⃝ Medications ⃝ Infections ⃝ Nutritional Status ⃝ Other:_______________________________ Evaluation Parameters: Treatment Facility: ______________________________________________ (Name) (Location) Dates: _______________________________________________________________ (Start) (End) Therapy Provided @ No Charge: ___________________ At the end of the pre-determined evaluation period, established rental rates will apply. (Signature/Date) Evaluator: __________________________________________________________________
NPWTTrialWoundAssessmentForms.docx