Outcomes Monitoring: 60 Day Survey - LIFE2000 Ventilation System

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*

LIFE2000 Ventilation System serial number can be found on the device’s information page by selecting the Wrench icon from the menu.

Serial Number (seven digit number)

How many hours have you been using the LIFE2000 Ventilation System daily?*

When are you using the LIFE2000 Ventilation System?*

How are you using the LIFE2000 Ventilation System?*

Do you have any barriers or challenges with using the LIFE2000 Ventilation System?*

If Yes, please explain.

If Other, please explain.

Since starting LIFE2000 Ventilation System therapy, have you had any hospital admissions for a respiratory illness?*

If Yes, how many?

Since starting LIFE2000 Ventilation System therapy, have you required an ER Visit for a respiratory illness?*

If Yes, how many?

On a scale of (1-5) how well is your device helping you keep up with your level of daily activities?*

How would you rate the overall effectiveness of your LIFE2000 Ventilation System therapy? On a scale of 1-5 (5 being the best)*

Can you expand on the reasoning for your rating?

Do you feel using the LIFE2000 Ventilation System has improved your quality of life? On a scale of 1-10 (1 being not at all and 10 being most definitely)*

Can you expand on the reasoning for your rating?

What is the likelihood of you recommending the LIFE2000 Ventilation System 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 have any ideas to improve the LIFE2000 Ventilation System?*

Do you know how to contact Baxter?*

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

Can you expand on the reasoning for your rating?

*required

Respiratory Health

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