Annual PAP Therapy Review Questionnaire

Patient Name

Today's Date Today's Date

D.O.B

Family Physician

Email Address

1. Are you using your PAP machine every night? 1. Are you using your PAP machine every night? yes no

If no, please explain why:

2. Is your mask fitting comfortably and sealing well? 2. Is your mask fitting comfortably and sealing well? yes no

If no, please explain why:

3. Have you replaced your mask in the past year? 3. Have you replaced your mask in the past year? yes no

4. Have you replaced your filters in the past year? 4. Have you replaced your filters in the past year? yes no

5. Are you waking feeling refreshed and rejuvenated in the morning? 5. Are you waking feeling refreshed and rejuvenated in the morning? yes no

6. Are you experiencing any daytime sleepiness? 6. Are you experiencing any daytime sleepiness? yes no

7. Are you pleased with the overall effect PAP therapy has had on you and your health? 7. Are you pleased with the overall effect PAP therapy has had on you and your health? yes no

8. Do you have any concerns about your PAP therapy that need to be addressed at this time? 8. Do you have any concerns about your PAP therapy that need to be addressed at this time? yes no

If yes, please explain why:

Sitting and reading Sitting and reading 0 1 2 3

Watching TV Watching TV 0 1 2 3

Sitting inactive in a public space Sitting inactive in a public space 0 1 2 3

As a passenger in a car for an hour As a passenger in a car for an hour 0 1 2 3

Lying down in the afternoon Lying down in the afternoon 0 1 2 3

Sitting and talking to someone Sitting and talking to someone 0 1 2 3

Sitting quietly after lunch (no alcohol) Sitting quietly after lunch (no alcohol) 0 1 2 3

In a car and stopped for a few minutes In a car and stopped for a few minutes 0 1 2 3

TOTAL (please add your responses)

Additional comments or information about your PAP therapy (optional)