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Nursing Best Practice Guideline<br />
History of Previous leg ulcers ❏ Yes ❏ No<br />
Leg Ulcers<br />
Number of previous episodes _______<br />
Age of first occurrence _____________ OR Year of first occurrence ___________<br />
How long did it take the last ulcer to heal? ______________<br />
Have you been prescribed compression stockings? ❏ Yes ❏ No<br />
If Yes, Class of stocking: ❏ Class 1 (20-30 mm Hg) ❏ Class 2 (30-40 mm Hg)<br />
❏ Class 3 (40-50 mm Hg) ❏ Unknown<br />
How frequently do you wear stockings?<br />
❏ All of the time ❏ Daytime only ❏ Occasionally ❏ Never<br />
91<br />
How old are your current stockings? ❏ < 6 months ❏ ≥ 6 months<br />
Do you have problems with stockings? ❏ Yes ❏ No<br />
If yes, the problem is: ❏ Applying ❏ Discomfort ❏ Skin<br />
Reactions<br />
Were you treated with compression bandaging before<br />
❏ Yes<br />
❏ No<br />
If yes, specify: ❏ Unna Boot ❏ Long stretch (e.g., surepress)<br />
❏ Four layer (e.g., Profore) ❏ Other specify__________<br />
Did you experience any problems with the compression bandage?<br />
❏ Yes<br />
❏ No<br />
If yes, ❏ Skin reactions ❏ Discomfort ❏ Skin breakdown<br />
Have you had a Doppler ultrasound of your leg before? ❏ Yes<br />
❏ No<br />
If yes, when was the last time? ________________________<br />
© Loeb Health Research Institute, Clinical Epidemiology Unit
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