Sevierville Wound Care — Wound History Form

University Wound Care and Hyperbaric Center

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

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Wound Location(Required)

When did you first notice the wound?(Required)

Has it ever healed then reopened?(Required)

How did your wound start (wounding event)?(Required)

How have you been treating your wound until now?(Required)

Have you had any lab work done in the past month?(Required)

If yes, who ordered the labwork?

Have you tested positive for an antibiotic resistant organism (MRSA, VRE)?(Required)

Have you tested positive for osteomyelitis (bone infection)?(Required)

Have you had any tests for circulation on your legs?(Required)

If yes, where done?

Have you had any other problems associated with your wound, like infection, swelling or other issues?(Required)

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

Find a Doctor

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

Find a Doctor

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Sevierville Wound Care — Wound History Form

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