COALESIA — Medical questionnaire

1. About you

Full name Phone WhatsApp For communication with the physician and to receive the questionnaire link, use a phone number registered with WhatsApp. If you do not have WhatsApp yet, please install the app and register your number. Date of birth Age Country City Preferred language

Other contacts

Email Time zone

Caregiver / contact person Contact person phone

2. About the wound

What is bothering you most?

Is there an open wound or ulcer? *

Wound #1

Where is the wound? * When did you notice this wound? What happened before it appeared? Pain now

Wound measurements

Length, cm Width, cm Depth, cm

Wound bed Wound edges Periwound skin Is there fluid discharge from the skin surface or from a wound? *

Swelling Redness Purulent discharge Bad smell Black tissue

3. Warning signs

Fever or chills Rapidly spreading redness Heavy or uncontrolled bleeding Sudden severe pain Confusion or severe weakness Cold, pale or blue foot

If any of these signs are present, do not wait for an online assessment—seek local medical or emergency care.

4. About your health

Diabetes mellitus Venous disease Arterial disease Neuropathy Kidney disease Heart disease Limited mobility

Bowel movement frequency

Do you have any bowel disturbances?

Constipation Diarrhea Alternating constipation and diarrhea Bloating Pain or discomfort Blood or mucus in stool No disturbances

Other features or details

Antiparasitic treatment history

Have you previously completed antiparasitic treatment or a preventive course?

When did you complete the course? Which medicines or products did you use? Who recommended the course? Did you notice any changes in your well-being after the course?

Additional comment

What illnesses, operations or allergies do you have? What medicines do you take?

5. What you are doing now

What are you doing for the wound now?

Do you have a treating doctor? Which antibiotic did you take most recently, and when?

6. Photographs

Add 2–4 recent photographs.

One photograph showing the overall affected area
The remaining photographs as close-up views
If possible, include at least one photograph with a ruler placed next to the affected area so the doctor can assess its size

Take photographs in good lighting, without filters or image editing. You may upload up to 12 files. JPG, PNG, WEBP or PDF: up to 10 MB each; a short MP4, MOV or M4V video: up to 45 MB. Total selected files: up to 48 MB.

Choose photographs, video or documents

Newly selected files will be uploaded only when the questionnaire is finally submitted.

7. Before sending

What else do you want to ask or tell the doctor?

Important information before submitting the questionnaire

Support terms

I consent to processing my personal and medical information for a remote consultation and preparation of preliminary recommendations. I have read and understand the capabilities and limitations of remote preliminary assessment described above. I understand that I independently decide whether to use a recommendation received through the platform. Before starting, changing, or stopping treatment or using any medication or other product, I undertake to consult my own treating physician. I separately consent to anonymous use of photographs and clinical history for educational or scientific materials. Refusal does not affect medical support.

After submission, the information will be stored in the center’s protected administrative system.

Tell us what is bothering you

Wound or tissue injury

1. About you

2. About the wound

Wound measurements

Wound measurements

3. Warning signs

4. About your health

Antiparasitic treatment history

5. What you are doing now

6. Photographs

7. Before sending