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Choose the appropriate follow-up time?
Next Day 2 Week 3 Month 6 Month
Please read the following statements and choose either Yes or No.
1. Does the CPAP mask cause a stuffy nose?
Yes No
2. Does the CPAP mask cause a runny nose?
Yes No
3. Is the CPAP mask causing a dry mouth?
Yes No
4. Is the CPAP mask causing a sore throat?
Yes No
5. Are you using humidity?
Yes No
If answered yes, choose one: Cool Heated
6. Have you had any problems with claustrophobia?
Yes No
7. Has the mask been irritating your eyes or ears?
Yes No
8. Is your mask working ok in general for you?
Yes No
9. Has the quality of your sleep improved with CPAP use?
Yes No
10. Has your snoring stopped?
Yes No
11. Have you been using your ramp?
Yes No
12. Are you cleaning the equipment as directed?
Yes No
13. How many hours of sleep are you using CPAP?
Hours:
Comments:
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