CPAP Follow-up Questionnaire

To evaluate the compliance and efficacy of your CPAP treatment program, and to ensure you maintain a good level of health, we ask you to complete this Annual Assessment Form. For questions or additional information please contact your respiratory therapist or our Customer Service.



ASSESSMENT OF YOUR CONDITION

Your initial symptoms

Impact of CPAP treatment on your symptoms:

Drowsiness or need to sleep: Yes No   Eliminated Reduced Recurrent
Low energy or fatigue: Yes No   Eliminated Reduced Recurrent
Cognitive impairment, diminished capacity: Concentration Memory   Eliminated Reduced Recurrent
Emotional Status: Irritability Anxiety Depressive Eliminated Reduced Recurrent
Reduced productivity at work: Yes No   Eliminated Reduced Recurrent
Other: Yes No   Eliminated Reduced Recurrent


Comorbidities Risk factors for Sleep Apnea patients and other medical issues

Impact of CPAP on other conditions:

Do you have, or have you ever had:

Hypertension: Yes No   Eliminated Reduced Recurrent
Type 2 Diabetes: Yes No   Eliminated Reduced Recurrent
Stroke: Yes No   Eliminated Reduced Recurrent
Angina / infarct: Yes No   Eliminated Reduced Recurrent
Insomnia: Yes No   Eliminated Reduced Recurrent
Other: Yes No   Eliminated Reduced Recurrent


COMPLIANCE WITH TREATMENT

Adherence to therapy without memory card:

Estimate the time used each night:

Adherence to therapy with memory card:

Average number of nights used:

Average number of hours used per night:

Average number of nights used more than 4 hours:

Residual event index:

Non-adherence to therapy

Discontinuance of CPAP treatments due
to lack of perceived benefits:

Yes No

Discontinuance of CPAP treatments due
to undesirable side effects:

Yes No

Please specify side effects (e.g. dry throat, mask leaks, etc):

Other - please specify additional reasons (eg. financial, etc):



ALTERNATE TREATMENT METHODS

Using a mandibular advancement device:

Yes No

Adopted Positional Therapy (you have ceased to sleep on your back):

Yes No

Have undergone corrective ORL surgery (please specify):

Yes No

CPAP treatments were halted by physician due to significant weight loss:

Yes No