Survey - Supplemental Oxygen Use Survey - For People Requiring Oxygen

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Supplemental Oxygen Use Survey - For People Requiring Oxygen

Please provide us with your contact information. If we may call you, please provide us with your day time phone number.


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Question - Required - Have you been, or are you currently on supplemental oxygen?

Question - Not Required - If so, what medical device(s) do you use or have used in the past?
Please make between 1 and 5 selections from the choices below.

	Stationary oxygen concentrator (plugs into the wall)
	Standard gas cylinders/compressed oxygen tanks (ex. green tanks delivered and picked up by supplier)
	Liquid oxygen (large metal tank delivered by supplier, which is then used to fill a portable device)
	Home trans-fill machine with tanks (a machine that is plugged in at home and used to fill small, compressed oxygen tanks right in the home)
	Portable oxygen concentrator (battery operated)

Question - Not Required - Other, please specify.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Were you given a choice of companies when first prescribed oxygen?

Question - Not Required - Have you used or are you using liquid oxygen?

Question - Not Required - How have the issues you have experienced, or are still experiencing, related to oxygen affected your health?
Please make between 1 and 4 selections from the choices below.

	Less exercise tolerance
	Forced to stay in the hospital longer while the right oxygen was arranged
	Problems keeping oxygen saturation at an acceptable level with given equipment
	ER visit or readmittance to the hospital because of oxygen equipment failure, oxygen not working properly

Question - Not Required - Other, please specify.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What about how these issues you have experienced, or are still experiencing, related to affecting your quality of life?
Please make between 1 and 4 selections from the choices below.

	Limited in time away from the house
	Additional stress related to uncertain supply and/or payment
	Feeling isolated from family and friends
	Impacting my mood

Question - Not Required - Other, please describe.

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Is there anything else you would like to tell us about your issues with oxygen and how they have impacted your life and your family's life?

(Maximum response 255 chars, approx. 5 rows of text)

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