Outcomes Monitoring - 5 Day Survey - VOLARA System

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 - VOLARA System

Patient Name*

Patient Phone Number*

Volara System serial number is located on the back of the control unit.

Serial Number (seven digit number)

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.*

The trainer was on time and prepared.*

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

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

Notes or comments on previous choices

Are you able to perform your therapy as prescribed?*

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?

Do you need any review on how to reorder supplies and clean the equipment?*

Do you know how to contact Baxter if needed?*

What method of contact do you prefer for future follow ups?*

Any additional questions or comments?

*required

Respiratory Health

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