Knoxville Wound Care — Patient History Form

Please fill out this form before your first visit to the University Wound Care and Hyperbaric Center. For more information, please call the center at 865-305-5510.

Name(Required)
Address(Required)
Gender(Required)
MM slash DD slash YYYY
Do You Drive?(Required)
Do You Live Alone?(Required)
Emergency Contact Information(Required)
Name of emergency contact
For instance, spouse or partner, parent, sibling, etc.
Referring Physician Information(Required)
Who referred you to the Wound Center?
Address(Required)
Who Is Your Primary Doctor?(Required)
Who handles your primary care?
Address(Required)
Were you referred to us via home health care or a nursing home? Please list the name of the organization here.
Your Pharmacy Name(Required)
Do You Have Any of the Following?(Required)
Patient's Medical History (Please check Yes or No for each item)
Other Patient Medical History Information
MM slash DD slash YYYY
Do You Have Any Implantable Devices?(Required)
Family Medical History - please indicate if any of your family members have/had this condition.
Cancer(Required)
Diabetes(Required)
Heart Disease(Required)
Hereditary Spherocytosis(Required)
Hypertension(Required)
Kidney Disease(Required)
Lung Disease(Required)
Seizures(Required)
Stroke(Required)
Thyroid(Required)
Tuberculosis(Required)
Please list name of hospital, purpose of hospitalization and date.
If you have any additional comments or notes, please write them here.

Contact Info
University Wound Care and Hyperbaric Center
1924 Alcoa Highway
Medical Building E, Suite 40
Knoxville, TN 37920
Phone: 865-305-5510
Fax: 865-305-5515

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Contact Info
University Wound Care and Hyperbaric Center
1924 Alcoa Highway
Medical Building E, Suite 40
Knoxville, TN 37920
Phone: 865-305-5510
Fax: 865-305-5515

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