Outcomes Monitoring: 30 Day Survey - THE VEST Airway Clearance System

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

Outcomes Monitoring: 30 Day Survey - THE VEST Airway Clearance System

Patient Name*

Patient Phone Number*

Usage Information

Please type the reading from the total use display in the field below. The display reads to the tenth of the hour. Confirm your device is turned on, at the Normal/Custom screen press the OFF button to obtain the hour meter reading.

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 (to one decimal point)*

Not Available

Serial Number (seven digit 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 VEST 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 reasons 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 THE VEST System therapy have you noticed any of the following improvements?* Decreased Shortness of Breath
Improved Quality of Sleep
Increased Energy
Other

If Other, please explain.

Do you know how to contact Baxter Respiratory Health?* Yes
No

What method do you prefer for future follow ups?* Phone
Email
Both

Any additional questions or comments?

*required

Contact a Respiratory Health representative for more information

Call us at (800) 426-4224 or Contact Us Online

Respiratory Health

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