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Patient/Care Giver - Home Oxygen Survey

 

*

1. I was prescribed oxygen in the following setting:

I was prescribed oxygen in the following setting:   Hospital Long Term Care Facility Family Physician

Other Comments

2. I am:

I am:   Male Female

3. My age is:

My age is:   < 40 40 - 50 50 - 60 60 - 70 > 70

4. VitalAire was recommended by a:

VitalAire was recommended by a:   Respirologist Family Physician Hospital Professional (RRT/RN) Clinic Staff List of Oxygen Providers Friend or Family Other (see comments)

Other (please specify)

5. I reside in the following Province

I reside in the following Province   BC AB SK MB ON QC NB NS PEI NL

6. Please rate the importance of the following to you:

	Not Important	Somewhat Important	Neutral	Very Important	Extremely Important
Range of oxygen products provided for your needs	*Please rate the importance of the following to you: Range of oxygen products provided for your needs Not Important	Range of oxygen products provided for your needs Somewhat Important	Range of oxygen products provided for your needs Neutral	Range of oxygen products provided for your needs Very Important	Range of oxygen products provided for your needs Extremely Important
Access to portable oxygen systems	Access to portable oxygen systems Not Important	Access to portable oxygen systems Somewhat Important	Access to portable oxygen systems Neutral	Access to portable oxygen systems Very Important	Access to portable oxygen systems Extremely Important
Response to your call	Response to your call Not Important	Response to your call Somewhat Important	Response to your call Neutral	Response to your call Very Important	Response to your call Extremely Important
Educational materials about my condition, operating instructions, hygiene and safety	Educational materials about my condition, operating instructions, hygiene and safety Not Important	Educational materials about my condition, operating instructions, hygiene and safety Somewhat Important	Educational materials about my condition, operating instructions, hygiene and safety Neutral	Educational materials about my condition, operating instructions, hygiene and safety Very Important	Educational materials about my condition, operating instructions, hygiene and safety Extremely Important
Advice on Activities of Daily Living	Advice on Activities of Daily Living Not Important	Advice on Activities of Daily Living Somewhat Important	Advice on Activities of Daily Living Neutral	Advice on Activities of Daily Living Very Important	Advice on Activities of Daily Living Extremely Important
Experience and expertise of VitalAire	Experience and expertise of VitalAire Not Important	Experience and expertise of VitalAire Somewhat Important	Experience and expertise of VitalAire Neutral	Experience and expertise of VitalAire Very Important	Experience and expertise of VitalAire Extremely Important
National Accreditation	National Accreditation Not Important	National Accreditation Somewhat Important	National Accreditation Neutral	National Accreditation Very Important	National Accreditation Extremely Important
Active follow-up to improve your therapy	Active follow-up to improve your therapy Not Important	Active follow-up to improve your therapy Somewhat Important	Active follow-up to improve your therapy Neutral	Active follow-up to improve your therapy Very Important	Active follow-up to improve your therapy Extremely Important
Sending reports to your doctor	Sending reports to your doctor Not Important	Sending reports to your doctor Somewhat Important	Sending reports to your doctor Neutral	Sending reports to your doctor Very Important	Sending reports to your doctor Extremely Important

Other (please specify)