Outcomes Monitoring: 3, 6, 12, or 24 Month 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 - 3,6,12, or 24 Month 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)

On a typical day in the past 2 weeks how would you rate your work of breathing during daily activities? On a scale of 1-10 (1 being the easiest and 10 being extremely difficult)*

Since starting VOLARA System therapy have you required a new antibiotic for a respiratory infection (not including routing antibiotic use)?*

If Yes, how many were IV?

Since starting VOLARA System therapy, have you had any hospital admissions for a respiratory illness?*

Since starting VOLARA System therapy, have you required an ER visit for a respiratory illness?*

Are you able to perform your therapy as prescribed?*

If Other, please explain.

How effective is VOLARA System in clearing your airways/keeping your airways clear?*

Can you expand on the reasoning for your rating?

If you have used previous airway clearance, how would you rate the effectiveness of VOLARA System versus other devices?*

Can you expand on the reasoning for your rating?

What is the likelihood of you recommending this therapy to others? On a scale of 1-10 (1 least likely to recommend and 10 most likely to recommend)*

Can you expand on the reasoning for your rating?

Do you need any replacement supplies?*

Do you know how to contact Baxter?*

How would you rate your overall experience with Baxter in regard to support with your therapy?*

Can you expand on the reasoning for your rating?

*required

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