Home Oxygen Survey (ALA)
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1. Please select the type of oxygen equipment that you use. Select all that apply.
stationary concentrator
standard gas cylinders
liquid oxygen
portable oxygen concentrator
Other (please specify)
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Other:
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2. Has the type of oxygen equipment you use changed?
Yes
No
I don't know
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3. What problems (if any) have you experienced regarding your supplemental oxygen? Select all that apply.
Bills not explained
Can't change companies
Can't mix systems
Company does not respond to calls
Delivery problems
Equipment not working
Incorrect or delayed physician orders
Lack of high flow portable systems
Lack of portable systems I can physically manage
Need or used to use liquid and can't get it
Not enough portable oxygen provided so I can work
Not enough tanks for activity outside home
Travel oxygen problems
Other
No problems
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4. Please tell us more about the problems you have experienced accessing your oxygen. It is important to understand what you have been told and who told you, what actions were taken by the company and the reasons they gave and anything else you think would be helpful to better understand the extent of the problems people in the community are facing and why they are occurring.
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First Name:
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Last Name:
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City:
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State:
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Zip Code:
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Phone Number:
Email Address:
Email:
Yes, I would like to receive e-mail from the American Lung Association
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Email Interests
Email Newsletters > National Newsletters -
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URL Paramater
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