3M™ Tegaderm™ High Performance Foam Adhesive Dressing Evaluation
Name of Evaluator
Title
Phone Number
Date
Health Care Facility Name
Department
Sales Representative
Phone Number
Do you presently use an adhesive foam dressing?
 Yes
 No
If yes, which brand_________________________
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Which Tegaderm TM High Performance Foam Adhesive Dressing did you try?
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 2 x 2 inch square
 1 inch round mini wrap*
 4 x 4 inch square
 2 1/2 x 3 inch oval
 1 1/4 x 1 1/2 inch mini oval  4 x 4 1/2 inch oval
 5 1/2 x 6 1/2 inch oval
 3 x 3 inch heel/elbow
Please check the sites where Tegaderm TM High Performance Foam Adhesive Dressing was applied:
 Coccyx
 Ischial
 Shoulder
 Foot
 Toe
 Sacrum
 Hip
 Elbow
 Heel
 Other:______________________
Please check the type of use:
 Skin Tear
 Cover dressing with wound filler  Diabetic foot ulcer  Venous ulcer

 Stage II pressure ulcer  Stage III/IV pressure ulcer
 Ischemic toe ulcer  Other:_________________
Was a skin barrier used?
 Yes
 No
Did you custom cut the dressing?
 Yes
 No
If yes, how did you reinforce the edge?
 Transparent Film
 Tape
 Other:__________________________________________________
Please rate TegadermTM High Performance Foam Adhesive Dressing as it compares to dressing you use most often:
Much Better
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Length of wear
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Periwound Skin
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Absorption
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Conformability
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Barrier Properties
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Prevent maceration
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Patient Comfort
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Ease of Application
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Overall Performance
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Adhesive Residue on Skin
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Nonadherency to wound bed
Better
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Same
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Worse
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Much Worse
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N/A
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Additional
Comments
* The mini wrap dressing is constructed of a conformable, absorbent, polyurethane foam pad with a highly breathable, non-waterproof, film
backing reinforced with soft cloth tape.
Skin & Wound Care Division
3M Health Care
3M Center, Building 275-4W-02
St. Paul, MN 55144-1000
USA
1-800-228-3957
www.3M.com/healthcare
3M Canada
P.O. Box 5757
London, Ontario N6A 4T1
Canada
1-800-364-3577
www.3M.com/ca/healthcare
Please recycle.
Printed in U.S.A.
© 3M 2002. Portions Copyright 2006, 2010.
All rights reserved.
3M and Tegaderm are trademarks of 3M.
Used under license in Canada.
70-2009-4382-0