Airway Clearance Assessment CF Adult AIRWAY CLEARANCE ASSESSMENTThere are no right or wrong answers to this survey. Please answer as truthfully as possible so we can work together to find the best airway clearance treatment(s) for you and your lifestyle.First NameLast NamePhysician*Name of Clinic*Phone # (optional)Email* 1. Which treatment methods are you currently using?Please select the devices/methods you use from the drop downs and indicate how frequently you use them.Treatment NameNumber of puffs or minutesTimes a day?Days a week?BronchodilatorsSelectProventil®ProAir®Ventolin®Xopenex®OtherHow many times a day?How long each time?How many times a week?Other Inhaled BronchodilatorsHypertonic SalineSelectHypersal®Pulmosal®3%3.5 %7 %How many times a day?How long each time?How many times a week?Mucolytics (Mucus Thinners)SelectMucomyst®Bronchitol®Pulmozyme®OtherHow many times a day?How long each time?How many times a week?Other Mucolytics/Mucus ThinnersAirway Clearance TherapiesTreatment NameNumber of puffs or minutesTimes a day?Days a week?Positive Expiratory Pressure (PEP)SelectResistex PEP MaskTheraPEP®How many times a day?How long each time?How many times a week?Oscillating Positive Expiratory Pressure (OPEP)SelectAcapella Choice®Aerobika®Flutter®Lung Flute®RC-Cornet®OtherHow many times a day?How long each time?How many times a week?Other OPEPVest Therapy (Mobile)SelectAffloVest®Monarch®How many times a day?How long each time?How many times a week?Vest Therapy (Stationary)SelectThe Vest®InCourage®SmartVest®How many times a day?How long each time?How many times a week?Huff CoughingHow many times a day?How long each time?How many times a week?Percussion and Postural DrainageHow many times a day?How long each time?How many times a week?Active Cycle of Breathing Techniques (ACBT)How many times a day?How long each time?How many times a week?Autogenic DrainageHow many times a day?How long each time?How many times a week?Intrapulmonary Percussive Ventilation (IPV)How many times a day?How long each time?How many times a week?Other:How many times a day?How long each time?How many times a week?Exercise: Please specify which type:How many times a day?How long each time?How many times a week?Inhaled AntibioticsSelectCayston®TOBI®TOBI Podhaler®Bethkis®Colistin®How many times a day?How long each time?How many times a week?Inhaled CorticosteroidsSelectFlovent®Pulmicort®QVar®How many times a day?How long each time?How many times a week?2. To what extent is each statement true for you?Check the box that best describes how closely each statement describes your experienceI can explain the benefits of airway clearance.*Not at all trueSomewhat trueTrueVery trueI am confident I know how to do my airway clearance correctly*Not at all trueSomewhat trueTrueVery trueI am satisfied with my current airway clearance routine*Not at all trueSomewhat trueTrueVery trueI know about all of the airway clearance options that are available to me*Not at all trueSomewhat trueTrueVery trueI do my airway clearance routine every day*Not at all trueSomewhat trueTrueVery trueI do my airway clearance routine when I am away from home*Not at all trueSomewhat trueTrueVery trueI know the correct order in which to do my respiratory treatments, including airway clearance*Not at all trueSomewhat trueTrueVery trueI know how to clean/disinfect my airway clearance equipment*Not at all trueSomewhat trueTrueVery trueI am comfortable doing airway clearance in front of friends/family*Not at all trueSomewhat trueTrueVery true3. Which of these might get in the way of doing your current airway clearance therapy (ACT) and/or might prevent you from adding a new ACT?Select all that applyCheck all items that apply to your situation.* I don’t think it helps I don’t think I need it I’m not producing sputum It takes too much time It disrupts my daily life It gets in the way of time with friends/family I would rather play sports/exercise It makes my cough worse It’s uncomfortable/hurts The equipment is difficult to set up I have issues with cleaning/disinfecting I’m not sure about the settings I forget to do it It reminds me of my CF It’s embarrassing I don’t want to do it when I’m away from home 4. Use this space to add any thoughts not addressed in the sections above Download your PDF Now review the form below to verify that it is complete and accurate, if necessary scroll back up to correct information. The preview should automatically load your information, if it does not click the reload icon below to reload it. Once you have verified all your information, click the Download PDF button to save the form to your computer. To protect your privacy we do not save your information, so be sure to move your file to a secure, accessible location after downloading. Your PDF
