Sevierville Wound Care — Patient History Form

Specialty Practices
University Wound Care and Hyperbaric Center
Sevierville Wound Care — Patient History Form

Prior to your visit to the Sevierville Wound Care Center, please complete the Medical Reconciliation Form and the Wound History Form online. If you have any questions, please contact our office at 865-446-3050.

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
1130 Middle Creek Road, Suite 110
Sevierville, TN 37862
Phone: 865-446-3050
Fax: 865-446-3135
Contact Info
University Wound Care and Hyperbaric Center
1130 Middle Creek Road, Suite 110
Sevierville, TN 37862
Phone: 865-446-3050
Fax: 865-446-3135
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