Report the use of the LifeVac device

Report the use of the LifeVac device
We understand that choking is a very scary experience, both for the victim and those witnessing and/or helping to try to remove an airway obstruction. We hope that everything turned out well in this situation, and that you are willing to take a few minutes to tell us about your experience. Please note, de-identified data will be used in promotion and advertising activities. No personal identifying information about the patient or rescuer will be shared without the express permission of those persons.
Date of the incident*

DayMonthYear
Date
Location of the incident

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Age of the choking person?*
MaleFemale
Name of choking person? (optional and not for publication)

First NameLast Name
Did the person have any relevant pre-existing health problems? (Please specify)*
If "none" just write NONE
What type of material did the person choke on?*
Complete obstruction (silent and couldn't cough effectively)Incomplete or partial obstruction (could cough effectively)Unknown
Back blowsChest ThrustsAbdominal ThrustsCPRNone of the above
Sitting (e.g. chair or wheelchair)Lying downStandingStable side position
Was the choking person conscious when the LifeVac was used?*
Number of times the LifeVac was operated? (i.e. place-push-pull sequences)*
YesNo
Duration of the incident (i.e. choking event until recovery time)*
YesNoUnsure
Was there any medical follow-up of the person and if so what were the findings? (e.g. complications)*
If 'None" just write NONE
Basic Life Support (CPR)Advanced Life SupportNurseDoctorParamedicNoneOther
What are your thoughts on the experience using the LifeVac device?*
Search engine (e.g. Google)Social media advertising (e.g. Facebook, Twitter, TikTok)Social media postTelevisionWord of mouthOther
YesNo
size 2 or P mask (paediatric)size 3 or S mask (small)size 4 or M mask (medium)size 5 or L mask (large)size 6 or XL mask (extra large)not sure
Please enter your name and details below, so we can send the replacement LifeVac and mask/s*

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com.au
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please verify that you are human*
Should be Empty: