Airway Device Assessment Form
Please complete the following assessment to evaluate airway device suitability.
Patient Name
*
First Name
Last Name
Device Type
*
Please Select
Endotracheal Tube
Laryngeal Mask Airway
Blind Nasal Intubation
Other
Device Model/Size
Assessment Result
*
Please Select
Suitable
Marginal
Unsuitable
Device Fit Comfort Level
*
1
2
3
4
5
Notes/Comments on Device
Symptoms or Difficulties Observed
Breathing Difficulty
Coughing
Stridor
Other
Additional Relevant Observations
Assessment Instructions and Protocols
*
Submit
Should be Empty: