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Classification: Standards of the wound documentation and outcomes by Ulcus cruris
Gender
M
F
Age
Site
Date of Inclusion
Visit
Page
Date of data entry
Baseline
Health insurance status
Statutory health insurance without supplementary insurance
Statutory health insurance with supplementary insurance
Private health insurance
No health insurance
Other health insurance
Name of the health insurance
Postal code
Family status
Partnership
Married
Divorced
Widowed
Single
Education
Without qualifications
Secondary school
High-school diploma
Advanced technical certificate
Higher education entrance qualification
Other qualification
Profession
Economically active
Administrative leave (e.g. parental leave)
Apprentice, conscript , voluntary social year
Pensioner
Early retirement
House wife/ househusband
Scholar/Student
Unemployed
Other
How many hours per week?
Other
Anamnesis
Height
Weight
Body mass index
Associated comorbidities
Cardio-vascular diseases
Hypertension
No
Yes
Cardiac insufficiency
No
Yes
Coronary heart disease
No
Yes
Peripheral arterial occlusive disease
No
Yes
Stage after Fontaine
Stage I
Stage IIa
Stage IIb
Stage III
Stage IV
CVI
No
Yes
Degrees according to Widmer
Degree I
Degree II
Degree IIIa
Degree IIIb
Lipedema / lymphedema
No
Yes
Others
No
Yes
Other
Metabolic disorder
Type 1 diabetes mellitus
No
Yes
Insulin-dependent diabetes
Not insulin-dependent diabetes
Type 2 diabetes mellitus
No
Yes
Hyperuricaemia
No
Yes
Dyslipoproteinemia
No
Yes
Malnutrition
No
Yes
Hepatic disorder
Hepatic cirrhosis
No
Yes
Steatosis hepatis
No
Yes
Other
No
Yes
Other
Rheum. und immunol. Disease
Spondylarthritis
No
Yes
Rheumatoide arhritis
No
Yes
Other rheumatoid diseases
No
Yes
Other rheumatoid diseases
Psychic and addiction diseases
Depression
No
Yes
Smoker
No
Yes
Ex-Smoker
No
Yes
Alcohol abuse
No
Yes
Other drugs
No
Yes
i.v. drug abuse
No
Yes
Status post
Malignant disease
No
Yes
Description
Infectious diseases
Tubercolosis
No
Yes latent
Yes active
Hepatitis
No
Yes, Hepatitis A
Yes, Hepatitis B
Yes, Hepatitis C
HIV
No
Yes
Other
No
Yes
Other
Associated medication
Pain therapy (WHO I)
No
Yes
Pain therapy (WHO II)
No
Yes
Pain therapy (WHO III)
No
Yes
Antibiotic therapy
No
Yes
Immunosuppressants
No
Yes
Anticoagulants
No
Yes
Others
No
Yes
Others
Nutritional status
Over
Under
Normal
Previous wounddressing
Alginate
Foam
Superabsorber
Other
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