Report Saved Life

INCIDENT DETAILS

Date of Choking Incident*

YOUR INFORMATION

Full Name*

Your Age*

Email Address*

Phone Number*

Address*

Suite or Apartment Number

Country*

State*

Zip Code*

Your level of training (BLS/ALS, etc.)

ABOUT THE INCIDENT

Patient Name*

Age of Patient*

Patient Gender*

City where the choking incident took place*

State 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

Were BLS protocols followed first? (e.g., 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 the patient 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