CPAP Follow-up Form

Use this form to evaluate the use of your respiratory equipment.

Required fields are highlighted.

Patient's Name:
Setup Date:
Machine:
Patient's Phone:
Email:
Date of Follow-up:
Patient's Date of Birth:
CPAP/BiPAP Level:
Type of Mask:
Physician:
Choose the appropriate follow-up time.

Next Day 2 Week 3 Month 6 Month

Remember to order mask, tubing and filter supplies every 6 months!

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 and if so what type?

Yes, Cool Yes, Heated No

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?
Comments:

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