Position Health Product Evaluation Program Thank you for your interest in Position Health products! PERSONAL INFORMATIONName* First Last Title*SpecialtyFacility NameCONTACT INFORMATIONFacility Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneEmail Would you like to receive our monthly e-mail bulletin for our product updates and featured clinical articles? Yes No PRODUCT EVALUATEDWhat model of Heelift product did you evaluate?Please evaluate ONLY ONE MODEL at a time. Heelift AFO ULTRA Heelift AFO Heelift GLIDE ULTRA Boot Heelift GLIDE Boot Heelift CLASSIC Boot Heelift TRACTION Boot Heelift Sizing Options Standard Petite Bariatric Heelift Sizing Standard Size Only Heelift Interior Options Smooth Foam (Edematous Legs) Convoluted Foam (Additional Ventilation) Bariatric Models come with Smooth Interior ONLY.Heelift Ultras Interior UltraTec Fluid-Repellent Liner Heelift Traction Interior Smooth Interior Only PATIENT DETAILSPatient AgePatient Gender Male Female Primary DiagnosisBraden ScoreIf other scale used, please list here.Did the patient have a heel pressure injury upon admission? Yes No Did the patient have a heel pressure injury upon boot application? Yes No Did the patient develop a heel pressure injury while wearing the boot? Yes No EVALUATE THE BOOT ON THE FOLLOWING CHARACTERISTICS: Please rate the following boot characteristics with a score between 1 (Poor) to 5 (Excellent).Offloads the heelPlease enter a value between 1 and 5.Fits the patientPlease enter a value between 1 and 5.Ease of application and removalPlease enter a value between 1 and 5.Stays in placePlease enter a value between 1 and 5.Moves along the sheetsPlease enter a value between 1 and 5.ComfortPlease enter a value between 1 and 5.Patient compliancePlease enter a value between 1 and 5.DurabilityPlease enter a value between 1 and 5.Temperature and moisture managementPlease enter a value between 1 and 5.Compared to other products, the Heelift Boot is: Superior Slightly Better Equal Slightly Inferior Inferior Additional Comments:NameThis field is for validation purposes and should be left unchanged.