| Date: |
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Name:* |
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| Address:* |
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Phone: |
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| Hours:*
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To determine hours on your machine, follow the steps below:
- * Respironics Remstar: Hours show in window on top of machine
- * Respironics Mseries: Hours show when you press the right arrow under flap.
- * ResMed Machines: Hours show when you press the left button once and then press the down arrow once. Press right button to exit menu.
- * Fisher Paykel: Hours show when you turn on the machine and press the triangle until you come to average hours used.
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| Days not used:
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Issues which caused the lack of CPAP use (illness, vacation, mask fit, sores, issues with machine operation,etc)?
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| Quality of sleep:
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| How do you feel when you are awake?
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| Has CPAP/BIPAP improved your quality of life? |
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None
Slightly
Moderately
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Mask Fit and Comfort: |
| Any pressure sores:
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Comments:
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| Any irritations on face/nose:
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Comments:
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| Are you experiencing any snoring while wearing a mask?
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Comments:
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| Do you have issues with dry nose or mouth?
Yes
No |
Comments:
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| Best way to reach you to resolve problems: |
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Home Phone
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Cell Phone
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Email
The email you are sending CressCare Medical is not encrypted. Therefore such confidential information, including account information and personally identifiable information is not secure. If we need to email you back, it will be in encrypted format. Use of non-encrypted email is inherently insecure. In no event shall CressCare accept any responsibility for the loss, use or misuse of any information including confidential information, which is sent t us via our web site. |
Email Consent Form:
If you wish to communicate with CressCare Medical via email in the future, we ask that you please print our 'Email Consent Form' sign it and bring or mail it in. |
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