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Mahiri Wound Management

Client Assessment Form

Client Assessment Form

Operations Assessor Details:

Client Number

Assessment Type

Current Date:

Current Time:

CLIENT DETAILS

Title:

First Name:

Middle Name:

Last Name

Building Name/No:

Street :

Town:

District:

City:

Country:

Digital Add./Zip Code:

CLIENT COMMUNICATION DETAILS

Email:

Mobile:

WhatsApp:

CLIENT PERSONAL DETAILS

Date of Birth (DOB):

Gender:

Relationship Status:

Occupation:

Employment Status:

NEXT OF KIN DETAILS

Next of Kin - Relationship:

Next of Kin - First Name:

Next of Kin - Last Name:

Next of Kin Mobile:

Next of Kin WhatsApp:

Next of Kin Email (If no email enter: ntbcfirstname.surname@mahiri-telehealth.com),

Next of Kin Photo

Upload Next of Kin Photo

Additional Information:

UPLOAD CLIENT IDENTITY DOCUMENTS

Client Photo:

Client ID Upload (Please take a picture of patient's face with ID next to it ):

Client ID Check:

Ghana Card

Passport

Driving License

Birth Certificate

REFERRED BY/RECOMMENDATIONS

WM Referral Type

Referring Institution Type (if applicable)

Hospital/Clinic

Not Applicable

Referring Institution Name:

CLIENT HEALTH STATUS

Existing Health Status (select all relevant):

Adult with mobility issues

Dementia

Diabetes

Diabetes Foot Problem

Foot Ulcer

Heart Attack

High Blood Pressure

Low Blood Pressure

Mental Issues

Nutritional/Dietry Issues

Old Age

Prenatal Woman

Postnatal Woman

Post Surgery Patient

Post Hospital Stay Patient

Respite Care

Sick Patient (Adolecent)

Sick Patient (child)

Sick/Fragile Patient (Elderly)

Stress

Stroke

No major or known issues

Other (please specify below):

Other - Specify

TYPE OF HOSPITAL STAY

Length of hospital stay:

VACCINATIONS

Has the client been vaccinated?

Covid in the last 6 months

Covid in the last 12 months

HIV in the last 6 months

HIV in the last 12 months

Monkey Pox in the last 6 months

Monkey Pox in the last 12 months

Other? Specify in the notes

New Field:

WOUND ASSESSMENT

Weight:

Height:

Nutrition Status

Smoking:

If client Is a Smoker - How many smoked per day?

Alcohol

If Client Drinks - How many units per week?:

Field label

CO-MORBIDITIES ASSESSMENT:

Diabetes Mellitus: Impairs blood flow and increases the risk of infection.

Immunodeficiency: Compromised immune system makes it harder to fight infections.

Peripheral Neuropathy: Nerve damage affecting sensation, leading to injury without awareness.

Peripheral Vascular Disease: Reduces blood circulation, hindering the delivery of nutrients to the wound site.

Obesity: Excess weight can strain blood vessels and impair wound healing.

Smoking/Tobacco Use: Reduces blood flow and oxygen delivery to tissues.

Aging: Slower healing due to reduced cell turnover and tissue regeneration.

Autoimmune Diseases: Conditions like rheumatoid arthritis can affect the immune response.

Hypertension: High blood pressure can impact blood flow to the wound site.

Malnutrition: Lack of essential nutrients hampers tissue repair and regeneration.

Chronic Kidney Disease: Impaired kidney function may affect wound healing.

Cancer: Both the disease and its treatments can compromise the healing process.

Steroid Use: Prolonged use of steroids can delay wound healing.

Venous Insufficiency: Impaired blood flow in the veins leading to chronic wounds.

Heart Disease: Reduced cardiovascular function affects blood circulation.

Chronic Respiratory Conditions: Conditions like COPD can impact oxygen delivery to tissues.

Dehydration: Insufficient fluid levels hinder the healing process.

HIV/AIDS: Weakens the immune system, increasing susceptibility to infections.

Thyroid Disorders: Thyroid imbalances can affect metabolism and healing.

Chronic Liver Disease: Impaired liver function may impact clotting and healing.

None

Uncertain

New Field:

WOUND ASSESSMENT DETAILS

Wound Location 1

Wound Type & Description 1

Wound Shape 1

Wound Length 1

Wound Depth 1

Wound Edges 1

Undermining 1

Necrotic Tissue Type 1

Necrotic Tissue Amount 1

Condition Surrounding Skin 1

Date of Wound

Pain Frequency 1

1. At Charnging of dressing

2, On movement

3. Continuous

4. Other

Pain Severity 1

Pain Assessment - Other 1

Field label

EQUIPMENT REQUIREMENTS:

Specialised Materess

Cushion

Heal Protector

Orthopedic Bed

Hoist

Other

Equipment Requirement Notes:

ANY ADDITIONAL NOTES

DO ADDITIONAL WOUNDS EXIST & REQUIRE ASSESSMENT?

CLIENT CONSENT INFORMATION

Capacity For Consent

I Give Consent & Opt-In

By checking, I have given consent and agree to share images of my wound and my form responses for the purposes of Mahiri-Telehealth/Mahiri HomeCare assessing my health needs and subsequent provision of a quotation and treatment plan. .

Images Upload

1. Upload Images Taken

2. Upload Images Taken

3. Upload Images Taken

4. Upload Images Taken

Upload Image (Optional)

ASSESSMENT PAYMENT INSTRUCTIONS

PAYMENT DETAILS

To Pay Assessment Fee

Yes

No

ACCOUNT NAME: MAHIRI-TELEHEALTH LIMITED BANK: ZENITH BANK (GHANA) LIMITED ACCOUNT SORTCODE.: 120108 ACCOUNT NUMBER: 6011220983 ADDRESS: Labone Branch, House No. F166-6, Adj. Jet Link, North Labone, Accra, Ghana Tel: +233 (0) 302 784 179/83

This is a completed Mahiri Wound Care Client Assessment Form.

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SERVICE CONTACT

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A Mahiri-Telehealth Limited Solution

Telephone: +233 (0) 206 2243997

www.remotecare.global

info@remotecare.global

CONTACT

Mahiri-Telehealth Limited

Email

www.mahiri-telehealth.com

info@mahiri-telehealth.com

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