SCHEDULE TELEHEALTH First Name Last Name Gender Gender Male Female Cell phone number Date of birth Where is your wound located? How long have you had the wound(s)? How did it occur? Are you taking any antibiotics for your wound? Select Yes No Do you have any allergies to any medications? Yes No Are you taking any medications? Yes No Do you have any past medical history? Yes No Do you have any known Family History of Diabetes? Yes No Do you smoke / use tobacco? Yes No Do you have a primary care physician? Yes No Send