Outcomes Monitoring: 5 Day Survey - The Synclara™ Cough System

Patient Name*

Patient Phone Number*

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

Serial Number

The following questions ask about The Synclara™ Cough System training session.

Since beginning therapy have you been to the ER (without admission) for respiratory complications?*

Since beginning therapy have you been admitted to the hospital for respiratory complications? If yes, how many times?*

Are you able to complete your therapy as prescribed?*

Other (please explain)

In the past 6 months, have you needed antibiotics for respiratory infections (not including routine antibiotic use)?* Yes
No

If yes, how many times?

Oral or IV?

How would you evaluate the overall therapy in meeting your needs?*

Please rate the effectiveness of your in home training.*

Did the trainer review how to clean the equipment?* Yes
No

Do you know how to reorder supplies and how often?* Yes
No

Are you using the auto or manual mode for therapy?* Automatic
Manual

Do you know how to contact HIllrom if needed?* Yes
No

Comments

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

*required

Respiratory Health