Outcomes Monitoring: 5 Day Survey - The Monarch® Airway Clearance 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.

Outcomes Monitoring: 5 Day Survey - The Monarch® System

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)*

The following questions ask about The Monarch® System training session. Please answer the following questions by choosing Yes or No. If your response is No, please feel free to explain or comment on the experience.

Overall, how would you evaluate the training you received?*

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

How would you evaluate how well the Trainer fit the device for you?*

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

How would you evaluate how well the Trainer explained the use of the device to you?*

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

Have you made any adjustments to the garment fit since the Trainer did the initial sizing?* Yes
No

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

Have you made changes to the frequency or intensity settings since the Trainer did the initial setup?* Yes
No

If yes, please explain. Why did you have to make changes to the settings? What did you adjust?

Have any of the PODs been turned off?* Yes
No

If yes, why were the POD(s) turned off? Select all that apply. Causing discomfort in that area
Don't feel it's needed in that area
POD was not working
Irritating an access port
Accidentally turned off
Other (please specify)

Other (please specify)

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

If no, please explain.

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

Comments

Clinical Follow-Up Please have a clinician contact me within the next 3 business days

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