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 NameHow Long?Times a day?Times a week?BronchodilatorsSelectProventil®ProAir®Ventolin®Xopenex®Serevent®Spiriva®OtherHow many times a day?How long each time?How many times a week?Other Inhaled BronchodilatorsHypertonic SalineSelectHypersal®Pulmosal®3 %7 %How many times a day?How long each time?How many times a week?Mucolytics (Mucus Thinners)SelectPulmozyme®Mucomyst®OtherHow many times a day?How long each time?How many times a week?Other Mucolytics/Mucus ThinnersAirway Clearance TherapiesTreatment NameHow Long?Times a day?Times a week?Positive Expiratory Pressure (PEP)SelectPEP ValvePEP MaskFlutterHow many times a day?How long each time?How many times a week?Oscillating Positive Expiratory Pressure (OPEP)SelectAcapella Choice®Aerobika®Lung Flute®OtherHow many times a day?How long each time?How many times a week?Other OPEPHigh-Frequency Chest Wall Oscillation (Mobile)SelectAffloVest®Monarch®How many times a day?How long each time?How many times a week?High-Frequency Chest Wall Oscillation (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®How many times a day?How long each time?How many times a week?Inhaled CorticosteroidsSelectPulmicort®QVar®Flovent®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 applies to each statement.I can explain the benefits of airway clearance.*Not at all trueA bit trueTrueVery trueI think my airway clearance is an important part of my care and makes me healthier.*Not at all trueA bit trueTrueVery trueI know about all of the airway clearance options that are available to me.*Not at all trueA bit trueTrueVery trueI know the correct order in which to do my pulmonary treatments, including airway clearance.*Not at all trueA bit trueTrueVery trueI consistently do my airway clearance routine each day.*Not at all trueA bit trueTrueVery trueI continue my airway clearance routine when I am away from home.*Not at all trueA bit trueTrueVery trueI am able to set aside time each day to perform airway clearance therapies.*Not at all trueA bit trueTrueVery trueI am confident I know how to do my airway clearance correctly.*Not at all trueA bit trueTrueVery trueI am confident I know how to clean/disinfect my airway clearance equipment.*Not at all trueA bit trueTrueVery trueI am comfortable doing airway clearance in front of friends/family.*Not at all trueA bit trueTrueVery trueI am satisfied with my current airway clearance routine.*Not at all trueA bit trueTrueVery true3. Which of the following might get in the way of doing your current airway clearance routine or adding a new airway clearance option?Check all items that apply to your situation.* I don’t think it helps It takes too much time It’s difficult to set up I forget to do it I’m not sure why I should do it It disrupts my daily life It’s too complicated It reminds me of my disease It makes my cough worse I can’t travel with it Issues with cleaning/ disinfecting It’s embarrassing It’s uncomfortable/hurts I prefer to exercise I‘m not sure about the settings I don’t want others to know I’m not feeling well enough to do it It gets in the way of social time I’m too tired Feeling great, no symptoms High out-of-pocket cost I don’t want to do it when I’m away from home On a modulator, don’t need it I don’t think I need it Other 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
