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1i7HM.D DRAFT7-2-76 D 4 4 TAINAY CHICIATI, ORJO 4207 Dear Friends: Thank vou for'vour kind renort on the lieimli~n Maneuver. I tonxder if I mirht imrose further and ask thnt you answcr as may of th following questions as you are able.. Location of Rescue:Home. Restaurant Institution... Other Deseribe Yes NO Synptors: Could the victin speak? -brcathe? Did'he 'turn blue? . Other color? Please diescribe appearance: Respiratory rovemonts? Conscious Unconscious Consciousto unco Please describe appearance Technigue of performinx the Heimlich Maneuver: Was'the victin sitting?. Standing,? How many times was the maneuver applied? Object causing, chcking?. If possible,draw approximate size and shape. Other methods used Please list in order of being uscd #first) Describe hack slap upside down mouth to mouth other was object forcefully expelled or removed fron mouth? (Deseribe). Any aftereffects of Heimlich Maneuver (describe) Yes No Drowning Self Arplication Victim Rescuer Name: Name: Address: Address! Age: Age: Occupation: Occuration: Did victim realize what was happening? Please describe briefly thoughts and cxperience. Where did rescuer learn of Maneuver? Company Bulletin .... Newspaper..... Magazine. Medical Journal Parphlet. .Other (describe Name of Publication: This information will be used for research purposes Signature ENCLOSTAE vou, H Le Q1;3