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THERMO CONTOUR MATTRESS TRIAL
Your Information
Name
Department
Hospital/Nursing Home
Telephone
email
Patient Information
Patients Risk Status (Norton/Waterlow Scale)
Medical condition of patient
Weight
Kilograms
Pounds
Sex
Male
Female
Age
Trial Information
Duration of trial
days
Did the patient find the mattress comfortable?
Yes
No
Did you find the mattress convenient?
Yes
No
What type of Pressure Relief product would you normally have used for the patient?
Nothing
Low Airloss Overlay
Inflatable Overlay
Sheepskin
Foam Overlay
Low Airloss Bed
Other
Is the cover liked by you?
Yes
No
Is the cover liked by the patient?
Yes
No
Is the cover easy to clean?
Yes
No
Did the patient have sores on admission?
Yes
No
If Yes, location of sores?
Sacrum
Yes
No
Buttocks
Yes
No
Heels
Yes
No
Other
Have the sores diminished during the trial?
Yes
No
Did the patient develop any pressure sores or marks during the trial?
Yes
No
If Yes, location of sores?
Sacrum
Yes
No
Buttocks
Yes
No
Heels
Yes
No
Other
Any comments you would like to add
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