Attention Ventilator Users! This form is designed to obtain data that IVUN can use to connect ventilator users more effectively with each other when medical or equipment problems arise or when new users need information and support.
Please assist IVUN by completing the following questionnaire about your ventilator use. If you do not use a ventilator, but know someone who does, please give this census to them.
NOTE: Please print this form and do not fill out online; it is not working at this moment.
IVUN Census
Diagnosis:
ALS
CCHS
COPD
Muscular dystrophy
Polio
SMA
Spinal cord injury
Other
How long have you used a ventilator?
Less than 1 year
1-5 years
6-10 years
11-20 years
More than 20 years
How many hours per day do you typically use a ventilator?
Less than 4 hrs/day
4-8 hrs/day
8-16 hrs/day
16-24 hrs/day
24 hrs/day
Do you use ONLY nocturnal ventilation?
Yes
No
Can you frog breathe?
How long can you breathe on your own?
Less than 2 minutes
2-5 minutes
5-10 minutes
10-30 minutes
30-60 minutes
More than 60 minutes
What assisted ventilation do you currently use?
Volume ventilator
Pressure support ventilator
Bi-level pressure support
Phrenic nerve pacing
Chest shell (cuirass)
Pneumobelt
Porta-Lung
Iron lung
What brand/model of ventilator(s) do you use? (For example, Puritan Bennett LP10, Pulmonetic Systems LTV1000™, Respironics BiPAP®, ResMed VPAP®, etc.)
What interface(s) do you use?
Nasal mask
Nasal pillows
Facial mask
Lipseal
Mouthpiece
Tracheostomy
What brand/model of interface(s)? (For example, Puritan Bennett ADAM nasal pillows™, Fisher & Paykel Oracle™, ResMed Mirage®, Respironics ComfortGel®, Fome-Cuf ® trach tubes, etc.
If you use a custom-made nasal mask or face mask, please describe it and who made it for you.
What brand of headgear do you use or have you made your own?
If you have a tracheostomy, do you use a speaking valve?
How do you prevent or lessen respiratory infections? (For example, using manually assisted coughing, the CoughAssist™, postural drainage, medicine, etc.)
Have you used a different form of ventilation in the past? (For example, switched from trach positive pressure to noninvasive or from iron lung to nasal mask) Please describe briefly when and why you changed:
How many ventilators do you have?
Your primary ventilator is:
Owned
Leased
It is paid for by:
You
Private insurance
Medicare/Medicaid
Government agency (non-US)
Your secondary ventilator is:
PERSONAL ASSISTANCE
How many hours per day of personal assistance do you use?
None
Less than 2 hours/day
2-4 hours/day
4-8 hours/day
8-16 hours/day
16-24 hours/day
24 hours/day
Who provides this assistance?
Personal attendant paid by you
Personal attendant paid by private insurance
Personal attendant paid by Medicare/Medicaid
Personal attendant paid by government (non-US)
Nurse paid by you
Nurse paid by private insurance
Nurse paid by Medicare/Medicaid
Nurse paid by government (non-US)
Family not paid
Family paid by you
Family paid by private insurance
Family paid by Medicare/Medicaid
Family paid by government (non-US)
PERSONAL DATA
Periodically, manufacturers ask if they can mail promotional flyers about new products to ventilator users. Do you want to receive this information?
What is your preference for other ventilator users to contact you:
Mail
Phone
email
Name (REQUIRED)
Address
City
State/Province
Zip/Postal Code
Country
Phone (include area/country code)
Fax (include area/country code)
email (REQUIRED)
Birthdate