Outcomes Monitoring: 30 Day Survey - MONARCH System

Home PagePatientsManage My TherapyOutcomes Monitoring: 30 Day Survey - MONARCH System

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

Patient Name*

Patient Phone Number*

Usage Information

Follow these steps to obtain your Hour Meter Reading (HMR) and Serial Number. From the Main screen, select ‘Menu’, ‘Device Information’, ‘General’, and finally ‘System Information’. Your HMR and Serial Number will appear, input that information below

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*

Not Available

Serial Number

Date (MM/DD/YYYY)*

On a scale of 1-5 with 1 being poor and 5 being excellent, how would you rate how well the Monarch System is meeting your needs?*

On a scale of 1-5 with 1 being poor and 5 being excellent, how would you rate the effectiveness at removing secretions?*

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

If No, select options 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.

What settings are you currently using?*

Since starting MONARCH System therapy have you noticed any of the following improvements? (check all that apply)* Decreased Shortness of Breath
Improved Quality of Sleep
Increased Energy
Other

Respiratory Health

Advancing respiratory health through innovative therapies

Hill-Rom® Respiratory Care