Outcomes Monitoring: 30 Day Survey - THE VEST APX 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.

Patient Name*

Patient Phone Number*

Usage Information

Please type the reading from the total use display in the field below. Include the hours and minutes. Confirm your device is turned on, then tap the info icon in the top right corner on the home screen to obtain the total therapy runtime.

If you are away from your device, please type the number 0 in the total therapy runtime field.

Total Therapy Runtime (hours:minutes)*

Serial Number (ten characters)

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 APX 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 APX System therapy have you noticed any of the following improvements?* Decreased Shortness of Breath
Improved Quality of Sleep
Increased Energy
Other

Respiratory Health

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