Outcomes Monitoring: 5 Day Survey - THE VEST Airway Clearance System

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Fill out the form below and a member of the Baxter Respiratory Health team will be in contact with you.

Outcomes Monitoring: 5 Day Survey - THE VEST Airway Clearance System

Patient Name*

Patient Phone Number*

Usage Information

Please type the reading from the total use display in the field below. The display reads to the tenth of the hour. Confirm your device is turned on, at the Normal/Custom screen press the OFF button to obtain the hour meter reading.

If you are away from your device, type the number 0 in the hours of use field and check the "Not Available" box.

Hours of Use (to one decimal point)*

Not Available

Serial Number (seven digit number)

Date (MM/DD/YYYY)*

Thinking about your recent in-home appointment, please indicate how much you agree with the next four statements about the trainer using a scale of 0 to 10, where 10 is strongly agree and 0 is strongly disagree.

The trainer was knowledgeable about the equipment.*

Notes

The trainer was on time and prepared.*

Notes

The trainer provided clear and understandable instructions on how to use my device safely.*

Notes

The trainer was respectful and professional in behavior and appearance.*

Notes

Have you made any adjustments to the settings since beginning therapy?* Yes
No

If Yes, what did you change?

Are you able to perform your therapy as prescribed?* Yes
No

If No, select reasons why. Comfort Fit
Comfort Settings
Garment Issues
Needs Retraining
Not Sick
Not Seeing Benefit
Not Tolerating
Operation of Equipment
Time/Busy
Other

If Other, please explain.

How would you rate the overall effectiveness of your therapy so far on a scale of 1-5 (5 being the best)?*

Can you expand on the reasoning for your rating?

What are your current settings?*

Are you on a 30-day trial?* Yes
No

If Yes, are you trialing a competitor device as well? Yes
No

Do you know how to contact Baxter Respiratory Health?* Yes
No

What method do you prefer for future follow ups?*

Any additional questions or comments?

*required

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