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Name

Contact Number

Email

Date

Address

Patient age

Indications (if any) eg. MS, Parkinson’s , wheelchair user, Bed ridden etc.?

Nature of the blockage (if known)

Partial or total blockage
Partial blockageTotal blockageUnknown

BLS Protocol first followed?
YesNo

Patient conscious at time of device use? (LifeVac)
YesNo

Position of patient when LifeVac applied? (sitting, lying down, recovery position, standing, etc.)

Number of uses of LifeVac attempted?

Hazard successfully dislodged with LifeVac?
YesNo

Duration of patient choking until recovery?

Outcome

Did patient receive medical examination afterwards due to BLS being performed
YesNo

What complications were found, if any, from examination

Review/analysis of the device by user

Experience handling other choking incidents

Views on device before choking incident occurred

Pro's to using the device

Con's to using the device

Critical assessment of the role the device played in the incident

Extenuating reasons for its deployment

Was it decided BLS protocols were not appropriate to follow