Annual PAP Therapy Review Questionnaire

Patient Name

Date

D.O.B (MM/DD/YYYY)

Family Physician

Email Address

Annual PAP Therapy Review Questionnaire

0 = no chance of dozing
2 = moderate chance of dozing

1 = slight chance of dozing
3 = high chance of dozing

Please click correct button	0	1	2	3
Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations? This refers to normal daytime activity over the past several weeks or months. Please check the number that applies to you:
Sitting and reading
Watching TV
Sitting inactive in a public place
As a passenger in a car for an hour
Lying down in the afternoon
Sitting and Talking to someone
Sitting quietly after lunch (no alcohol)
In a car and stopped for few minutes
TOTAL

Your continued success on PAP therapy is of great importance to us.
We want to ensure that your needs are met so that you can be guaranteed years of optimized therapy.

Due to illness and COVID isolation requirements, there may be times when we have to have an unscheduled closure of a local office. Please check our Facebook page for daily updates.

More information!

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?	Yes	No
If no, please explain why:

3. Have you replaced your mask in the past year?	Yes	No
4. Have you replaced your filters in the past year?	Yes	No
5. Are you waking feeling refreshed and rejuvenated in the morning?	Yes	No
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?	Yes	No
8. Do you have any concerns about your PAP therapy that need to be addressed at this time?	Yes	No

#101 -15 Canada Ave

Duncan, BC V9L 1T3

1255B Cliffe Avenue

Courtenay, BC V9N 2K3

277 Evergreen Road

Campbell River, BC V9W 5Y4

#3-5144 Metral Drive

Nanaimo, BC V9T 2K8

Annual PAP Therapy Review Questionnaire

Epworth Sleepiness Scale

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