Report Saved Life

INCIDENT DETAILS

Date of Choking Incident*

YOUR INFORMATION

Full Name*

Your Age*

Email Address*

Phone Number*

Address*

Flat or house number

Country*

State*

Postcode*

Your level of first aid training, if any

ABOUT THE INCIDENT

Name of the person who was choking*

Their age*

Their gender*

Town or city where the choking incident took place*

County where the choking incident took place*

Any indications? If not applicable, please enter N/A.

What was blocking the airway? If unknown, please enter Unknown.*

DETAILS

Partial or total blockage?*

Partial Total Unknown

Position of patient when Exhaly applied?*

Was patient conscious at time of Exhaly use?*

Yes No

Was standard first aid tried first? (back blows, abdominal thrusts)*

Yes No

Number of times Exhaly attempted?*

Was the hazard successfully dislodged with Exhaly?*

Yes No

Do you feel Exhaly saved the life of the person choking?*

Yes No

Please elaborate

Did they receive a medical examination afterwards?*

Yes No

Any other details you'd like to share?

OTHER INFORMATION

Date of Exhaly Purchase or Gift Received*

How did you hear about Exhaly?*

Relation to patient*

Any experience handling other choking incidents?

Which Exhaly kit did you use?*

I affirm that the information entered in this document is accurate and complete*

Account

Have You Used Exhaly in a Choking Emergency?

INCIDENT DETAILS

INCIDENT DETAILS

YOUR INFORMATION

ABOUT THE INCIDENT

DETAILS

OTHER INFORMATION