Outcomes Monitoring: 30 Day Survey - The Monarch® System

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Fill out the form below and a member of the Hillrom 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)*

Please answer the following questions by choosing the appropriate response.

Overall, how would you evaluate the Monarch® System in meeting your needs?*

If you rated Good, Fair, or Poor what concerns or challenges are you having?

How would you evaluate the mobility enabled by the device?*

If you rated Good, Fair, or Poor what concerns or challenges are you having?

How would you evaluate the effectiveness of the device at removing secretions?*

If you rated Good, Fair, or Poor what concerns or challenges are you having?

How would you evaluate the overall comfort of the device relative to your expectations?*

If you rated Good, Fair, or Poor what concerns or challenges are you having?

How would you evaluate the ease of using the pendant?*

If you rated Good, Fair, or Poor what concerns or challenges are you having?

How would you evaluate the ease of charging the battery?*

If you rated Good, Fair, or Poor what concerns or challenges are you having?

How would you evaluate the ease of removing and cleaning the Vest Shell?*

If you rated Good, Fair, or Poor what concerns or challenges are you having?

Have you made any adjustments since we last contacted you (approximately one week after training)?* Yes
No

If yes, please explain. Why did you have to make adjustments? What did you adjust?

What other types of vest-type therapy have you used previously? Select all that apply* The Vest® Airway Clearance System, Hillrom
Incourage® System - Philips-Respirtech
SmartVest® System - Electromed
AffloVest® System - International Biophysics Corp.
Other (Please Specify)
Don't Know
I have not used other devices previously

Other (please specify)

Why did you decide to begin using the Monarch® System?*

How would you compare the effectiveness of the Monarch® System to your previous device(s)?*

Are you using the Connex® App on your smartphone?* Yes
No

If no, please explain why you aren't using the Connex® App on your smartphone.

How would you rate your satisfaction with the Connex® App?*

If you rated Good, Fair, or Poor what concerns or challenges are you having?

Do you know how to contact Hillrom Respiratory Health if you have questions or need help?* Yes
No

What is your likelihood to recommend the Monarch® System to others in need based on your experience so far with the device? Please provide your evaluation on a scale of 10 to 0 where 10 is Extremely Likely and 0 is Not at all Likely.*

Why do you say that?

Any other positive comments?

Do you have any concerns or ideas to improve the therapy? What would you change?

*required

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