CliniMed Appeel® Spray Evaluation Form

Clinimed Appeel® Medical Adhesive Remover Spray

Thank you for looking at this evaluation form.

 

The first questions concern your experiences BEFORE you started using the Appeel medical adhesive remover spray.

 

Questions 1-15 concern your experiences while using Appeel medical adhesive remover spray.

Patient's name / Initials *
Age*
Sex*
Community  
Hospital  
Name of Hospital
Unit/Ward
Member of staff in charge of evaluation
Previously, was an adhesive remover routinely used for this patient?
What was the brand of adhesive remover used?
What was the adhesive removed used to remove?
Based on previous dressing changes, please indicate on a scale of 0 to 10 what level of pain was caused by the removal of the dressing/s. (0=no pain and 10=greatest pain)
1. What was the condition of the skin that the adhesive part of the dressing was adhered to, prior to use of Appeel®?
2. What was the adhesive remover used to remove?
3. Did you use the Appeel® Spray to remove the adhesive product or residue left on the skin?
   
4. Did you use the Appeel® Spray directly onto the adhesive to be removed or spray it into the cap and dripped it onto the adhesive?
   
5. Did Appeel® Spray effectively remove the product / residue?
6. Did you find Appeel® Spray easy to use?
7. Was there any stinging on application?
8. Please indicate on a scale of 0 to 10 what level of pain was experienced by the removal of the dressing/s when using Appeel® Spray? (0=no pain and 10= greatest pain)
9. Was any damage caused to the peri-wound skin by removal of the dressing?
10. What was the condition of the skin that the adhesive part of the dressing was adhered to, after the use of Appeel®?
11. Was a dressing applied immediately after using the Appeel® Spray?
12. Was the application of the new dressing affected at all by the use of the Appeel® Spray?
   
13. Do you intend to continue to use Appeel® Spray for this patient's needs in the future?
14. In your experience of using Appeel® Spray, do you feel that EB patients would benefit from using the product?
15. Has Appeel® spray enabled you to now use a wider selection of dressings?
Any other Comments
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