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Incontinence Clinical Evaluation Form

To create your custom Clinical Evaluation Form, start by entering the following information:

Your Name:		Click here to print the full list of questions. Click here to print a sample of a finished form.
Facility Name:
Unit:
Sage Product #:
Return Form To:

Next, check the boxes next to the questions you would like to have printed on the form. A maximum of 10 questions can be selected. When finished, click "Next Step."

I recognize the importance of skin cleansing and barrier application in maintaining perineal skin integrity, and Comfort Shield® helps me better facilitate this process.

Comfort Shield® makes it easier to follow my unit's incontinence skin care protocol.

Comfort Shield's® mild cleansing formula is an improvement over our current soap/cleanser, barrier cream(s) and other products.

Comfort Shield® washcloths effectively cleaned the perineal skin.

Comfort Shield® washcloths were smooth and comfortable on my patient's skin.

Comfort Shield® washcloths were easy to use.

Comfort Shield® saved considerable time versus the current method.

With Comfort Shield®, I decreased the amount of linens, washcloths, towels, cleansers, moisturizers and barriers used vs. previous methods of incontinence care.

Comfort Shield® replaces other incontinence care products. (Circle all that apply: washcloths, wipes, basins, cleansers, soaps, moisturizers, barrier creams/ointments)

I believe Comfort Shield's® cleansing/protective washcloths are an improvement in the quality of patient care at this facility.

My patients prefer Comfort Shield® over previous methods of incontinence care.

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