CHART 1.

Data collection protocol for patients with venous ulcers

	I)				Identification:
Patient Name:					ID: Date of Birth: ___/___/___
					Date of First Visit: ___/___/___
				II)	Ulcer Characteristics:
					ULCER 1	ULCER 2	ULCER 3	ULCER 4	ULCER 5
DURATION
LOCATION
REGION OF LIMB
CRITICAL COLONIZATION
INFECTION
CAUSE
	Ulcer Area
	Area at First Visit (T0):
	Area at 6-Month Follow-Up (T6):
	Area at 12-Month Follow-Up (T12):
	III)	Comorbidities:
	1) HTN ( )	2) DM ( )	3) CHF ( )	4) Smoking ( )
	IV)	Treatment:
	1)	Number of visits at the outpatient ulcer clinic:
	2)	Type of compression therapy:
		- Elastic stocking ( )
		- Elastic bandage ( )
		- Unna boot ( )
		- Other ( ) Please specify _____________________
	III)	Comorbidities:
	1) HTN ( )	2) DM ( )	3) CHF ( )	4) Smoking ( )
	IV)	Treatment:
	1)	Number of visits at the outpatient ulcer clinic:
	2)	Type of compression therapy:
		Elastic stocking ( )
		- Elastic bandage ( )
		- Unna boot ( )
		- Other ( ) Please specify _____________________