COALESIA Patient Program — Initial Patient Assessment

1. Patient information

Full name Date of birth Age Country City Preferred language Phone WhatsApp Email Time zone

Caregiver / contact person Contact person phone

2. About the wound

Main complaint

Wound location Number of wounds How long it has existed How it started Pain level 0–10

Standardized wound measurements

Length, cm Width, cm Depth, cm

Wound bed Wound edges Periwound skin Exudate amount

Swelling Redness Purulent discharge Bad smell Black tissue

3. Urgent 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. Medical history

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

Bowel function

How often do you have a bowel movement?

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

Diagnoses, operations, allergies and medication

5. Current wound care

How is the wound currently treated?

Local treating physician Last antibiotic and date

6. Photos and documents

Please upload:

Overall view of the affected area
Complete wound view
Close-up of the wound
Photo with a ruler or other measuring reference
A comparison photo when possible

Use good natural light and no filters. Maximum 12 files, up to 10 MB each. JPG, PNG, WEBP or PDF.

Choose files

7. Consent and submission

Additional information

I consent to processing my personal and medical information for remote assessment. I understand that remote assessment is not a final diagnosis and does not replace in-person or emergency care. I separately consent to anonymous use of photographs and case 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.

Initial Remote Clinical Assessment Form

Wound or tissue injury