Obstructive Sleep Apnea/CPAP Follow-up

Name (Last, First, M.I.):

M F

DOB:

How your CPAP has effected your sleep
Check one

Worse
Unsure
Mild Improvement
Moderate Improvement
Significant Improvement

Comments

CPAP QUESTIONS

What type of mask do you wear?

Nasal Mask
Nasal and Mouth Mask

Do you use your CPAP every night?

Yes
No

How many hours (on average) do you use your CPAP each night?

Hours

Do you use your CPAP during ALL naps?

Yes
No

Does anyone report that you snore while wearing CPAP?

Yes
No

Do you ever wake-up with your CPAP mask off and/or unsure how it came off?

Yes
No

       If so, how often does this occur? /Week

While using CPAP, do you wake up with a dry mouth?
Yes
No

     If yes, how often does this occur? /Week

Do you suffer from nighttime nasal congestion?

Yes
No

EPWORTH SLEEPINESS SCALE

How likely are you to fall asleep in the following situations?

0 = Never     1 = slight chance     2 = moderate chance     3 = high chance

Sitting and reading
0     1     2     3

Watching TV
0     1     2     3

Sitting, inactive in a public place (e.g. theater or a meeting)
0     1     2     3

As a passenger in a car for an hour without a break 
0     1     2     3

Lying down to rest in the afternoon when circumstances permit
0     1     2     3

Sitting and talking to someone
0     1     2     3

Sitting quietly after a lunch without alcohol
0    1     2     3

In a car, while stopped for a few minutes in the traffic
0     1     2     3

    Total Score out of 24=