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Your name Your E-mail address exsalt® wound dressing used exsalt® SD7 exsalt® T7 both Please specify wound location Did you like exsalt®? Yes No Undecided Please give explanation, what did you like or not like? Did your patient provide any feedback while using exsalt®? Please provide comments. Would you recommend the use of exsalt®? Yes No Undetermined If not, why not? Would you like to further investigate the use of exsalt® in your facility? Yes No Undecided Based on overall dressing performance, rate exsalt® Ease of use Select one 1 - Poor 2 3 4 5 - Excellent Conformability Select one 1 - Poor 2 3 4 5 - Excellent Patient comfort during dressing changes Select one 1 - Poor 2 3 4 5 - Excellent Patient comfort during wear time Select one 1 - Poor 2 3 4 5 - Excellent Overall wound healability Select one 1 - Poor 2 3 4 5 - Excellent For how many weeks did you use exsalt®? Rate exsalt®'s ability to improve the following local signs and symptoms of wound bioburden Stalled healing Select one 1 - Poor 2 3 4 5 - Excellent N/A Friable and bright red granulation tissue Select one 1 - Poor 2 3 4 5 - Excellent N/A Exudate Select one 1 - Poor 2 3 4 5 - Excellent N/A Malodour Select one 1 - Poor 2 3 4 5 - Excellent N/A Localized edema Select one 1 - Poor 2 3 4 5 - Excellent N/A Pain Select one 1 - Poor 2 3 4 5 - Excellent N/A Induration and erythema extending well beyond borders Select one 1 - Poor 2 3 4 5 - Excellent N/A Wound breakdown and/or satellite areas of breakdown Select one 1 - Poor 2 3 4 5 - Excellent N/A What care did the patient receive before the exsalt® sample evaluation? If you use a silver dressing before you tried exsalt®, please provide the following information Dressing name Length of time used Frequency of dressing changes Additional Comments Please type the characters shown
