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 *

Male

Female

Community

Hospital

Name of Hospital

Unit/Ward

Member of staff in charge of evaluation

Previously, was an adhesive remover routinely used for this patient?

Yes

What was the brand of adhesive remover used?

What was the adhesive removed used to remove?

Dressing

Tape

IV Dressing

Other

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)

0
1
2
3
4
5
6
7
8
9
10

Comments

1. What was the condition of the skin that the adhesive part of the dressing was adhered to, prior to use of Appeel®?

Good

Dry

Red

Sore

blistered

broken

Comments

2. What was the adhesive remover used to remove?

Dressing

Tape

IV Dressing

Other

3. Did you use the Appeel® Spray to remove the adhesive product or residue left on the skin?

Adhesive product

Residue

Both

Comments

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?

Sprayed it onto the adhesive to be removed

Sprayed it first into the cap of the canister and dripped it onto the adhesive to be removed

Sprayed it first into the cap of the canister and used a cotton bud to put it onto the adhesive to be removed

Comments

5. Did Appeel® Spray effectively remove the product / residue?

Yes

Comments

6. Did you find Appeel® Spray easy to use?

Yes

Comments

7. Was there any stinging on application?

Yes

Comments

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)

0
1
2
3
4
5
6
7
8
9
10

Comments

9. Was any damage caused to the peri-wound skin by removal of the dressing?

Yes

Comments

10. What was the condition of the skin that the adhesive part of the dressing was adhered to, after the use of Appeel®?

Good

Dry

Red

Sore

Blistered

Broken

Comments

11. Was a dressing applied immediately after using the Appeel® Spray?

Yes

Comments

12. Was the application of the new dressing affected at all by the use of the Appeel® Spray?

The new dressing stuck as normal

The new dressing would not stick

The new dressing stuck better than before

13. Do you intend to continue to use Appeel® Spray for this patient's needs in the future?

Yes

Comments

14. In your experience of using Appeel® Spray, do you feel that EB patients would benefit from using the product?