Outcomes Monitoring: 30 Day Survey - The Vest® Airway Clearance System

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*

Patient Date of Birth (MM/DD/YYYY)*

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)*

Please answer the following questions by choosing a number one to six.

The therapy helps me clear secretions from my lungs*

The therapy helps me manage my respiratory health at home*

Using this therapy helps me have more energy to do my regular activities of daily living*

The therapy helps to minimize my shortness of breath*

Using this therapy helps my quality of sleep*

The therapy helps me feel better*

I would like to continue with this therapy*

How many users are there for this device?*

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.

What is your likelihood to recommend the Connex® App to others based on your experiences?*

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

*required

Respiratory Health

Advancing respiratory health through innovative therapies

Hill-Rom® Respiratory Care