Respiratory Device Intake Assessment Form
Please complete this assessment to help us better understand your respiratory device needs and current usage.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which best describes your current use of respiratory devices?
*
Currently use a respiratory device
Previously used but not currently
Never used a respiratory device
What type of respiratory device do you use most frequently?
*
Please Select
CPAP
BiPAP
Nebulizer
Oxygen Concentrator
Other
How often do you use your respiratory device?
*
Daily
Several times a week
Occasionally
Rarely
Please rate your overall satisfaction with your current respiratory device.
*
1
2
3
4
5
Indicate your level of agreement with the following statements about your current device.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The device is comfortable to use
1
2
3
4
5
The device is easy to operate
6
7
8
9
10
The device meets my needs
11
12
13
14
15
I am confident using the device
16
17
18
19
20
What challenges or concerns do you have regarding your respiratory device?
Is there any additional information you would like to share about your respiratory device needs?
Submit Assessment
Should be Empty: