South West Regional Wound Care Program Interdisciplinary Lower Leg Assessment Form Page 2
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3Person’s Name: ________________
ID Number: ________________
Date: ________________
SKIN & ANATOMY
Right Leg
Left Leg
Venous Signs & Symptoms
Arterial Signs & Symptoms
Venous Signs & Symptoms
Arterial Signs & Symptoms
Varicosities/spider veins
Hairless
Varicosities/spider veins
Hairless
Also seen with
Also seen with
Hemosiderin staining
Thin
Hemosiderin staining
Thin
Neuropathy
Neuropathy
Chronic
Shiny
Chronic
Shiny
Lipodermatosclerosis
Dependent rubor
Lipodermatosclerosis
Dependent rubor
Acute lipodermatosclerosis
Blanching on elevation
Acute lipodermatosclerosis
Blanching on elevation
Stasis dermatitis
Feet cool/cold/blue
Stasis dermatitis
Feet cool/cold/blue
Atrophie blanche
Toes
Atrophie blanche
Toes
Woody fibrosis
cool/cold/blue/gangrenous
Woody fibrosis
cool/cold/blue/gangrenous
Ankle (submalleolar) flare
Lower temperature in right
Ankle (submalleolar) flare
Lower temperature in left
Ulcer base shallow, moist
leg compared to left
Ulcer base shallow, moist
leg compared to right
with granulation &/or yellow
Capillary refill time: > 3
with granulation &/or yellow
Capillary refill time: > 3
slough/ fibrin, & irregular
seconds
slough/ fibrin, & irregular
seconds
edges
Ulcer located on foot or
edges
Ulcer located on foot or
Ulcer located in gaiter
toes
Ulcer located in gaiter
toes
region (lower 1/3 of calf)
Ulcer base pale and
region (lower 1/3 of calf)
Ulcer base pale and
Ulcer located superior to
dry&/or contains eschar
Ulcer located superior to
dry&/or contains eschar
the medial malleolus
Ulcer round and punched
the medial malleolus
Ulcer round and punched
Scarring from prev. ulc.
out in appearance
Scarring from prev. ulc.
out in appearance
Edema (pitting or firm)
Gangrene wet/dry
Edema (pitting or firm)
Gangrene wet/dry
Family history of venous
Family history of arterial
Family history of venous
Family history of arterial
disease
etiology
disease
etiology
History of DVT
Heart disease, CVA, MI
History of DVT
Heart disease, CVA, MI
Significant previous lower
Diabetes
Significant previous lower
Diabetes
leg injury
PVD
leg injury
PVD
Previous vein surgery
Intermittent claudication
Previous vein surgery
Intermittent claudication
Prior history of leg
Smoking
Prior history of leg
Smoking
ulceration
Ischemic rest pain
ulceration
Ischemic rest pain
Obesity
Obesity
Sedentary lifestyle
Sedentary lifestyle
ULCER OR PRE-ULCEROUS CONDITIONS
Right Leg
Left Leg
History of Previous Ulcer? Years _____________________
History of Previous Ulcer? Years _____________________
Date of Onset of Current Ulcer? _____________________
Date of Onset of Current Ulcer? _____________________
Multiple Wounds
Multiple Wounds
Locations:
Locations:
Skin stretched with imminent breakdown
Skin stretched with imminent breakdown
Serous weeping from leg without signs of ulceration
Serous weeping from leg without signs of ulceration
Sub-keratotic hemorrhage under callus
Sub-keratotic hemorrhage under callus
Probes to bone
Probes to bone
UNUSUAL ULCER
Unusual location:
Unusual appearance:
Present longer than 6 months with failure to respond to optimal treatment
ACTIONS:
Request tissue biopsy for wounds that suggest malignant growth or if the wound is non-responsive to best practices
X
S ig n a t u r e a n d D e s ig n a t io n
SWRWCP: B.7.1_Interdisciplinary Lower Leg Assessment Form_Jan_16_2011_Rev_Jan_2014
Page 2
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