Airway Clearance Assessment 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.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 Bronchodilators:SelectProventil®Ventolin®ProAir®Xopenex®Serevent®Spiriva®OtherHow many times a day?How long each time?How many times a week?Other Inhaled BronchodilatorsMucolytics/Mucus ThinnersSelectHypertonic Saline 3%Hypertonic Saline 7%OtherHow many times a day?How long each time?How many times a week?Other Mucolytics/Mucus ThinnersAirway Clearance TechniquesHow many times a day?How long each time?How many times a week?Positive Expiratory Pressure (PEP)SelectPEP ValvePEP MaskHow 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 OscillationSelectAffloVest®The Vest®InCourage®SmartVest®Monarch®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?Chest Physical Therapy (CPT)How many times a day?How long each time?How many times a week?Postural Drainage & PercussionHow 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?Other: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 am able to explain the benefits of airway clearance.*Not at all trueA bit trueTrueVery trueI believe airway clearance is an important part of my care and makes me healthier.*Not at all trueA bit trueTrueVery trueI am aware of all of the airway clearance options that are available to me.*Not at all trueA bit trueTrueVery trueI feel confident I know how to do my airway clearance correctly.*Not at all trueA bit trueTrueVery trueI consistently do my airway clearance routine each day.*Not at all trueA bit trueTrueVery trueI am satisfied with my current airway clearance routine.*Not at all trueA bit trueTrueVery trueI continue doing my airway clearance routine when I am traveling.*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 able to set aside time each day to perform airway clearance.*Not at all trueA bit trueTrueVery trueI feel confident I know how to take care of my airway clearance equipment.*Not at all trueA bit trueTrueVery trueI know the correct order in which to use my different pulmonary treatments, including airway clearance.*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.* High out-of-pocket cost I don’t think it helps me Issues cleaning/disinfecting It’s difficult to set up I don’t think I need it It may cause bleeding It’s too complicated I’m not sure why I should do it It reminds me of my disease It takes too much time I forget to do it It’s embarrassing It disrupts my daily life It’s uncomfortable/hurts I don’t want others to know I can’t travel with it It makes my cough worse None of these Prefer to exercise Gets in the way of social time 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
