Patient Compliance Form

(required = * )

Date:		Name:*
Address:*		Phone:
Hours:*
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 Macines: 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.
Days not used:
Issues which caused the lack of CPAP use (illness, vacation, mask fit, sores, issues with machine operation,etc)?
Quality of sleep: Good Fair Poor
How do you feel when you are awake? Tired Somewhat Tired Rested
Has CPAP/BIPAP improved your quality of life?
None Slightly Moderately Extremely
Mask Fit and Comfort:
Any pressure sores: Yes No
Comments:
Any irritations on face/nose: Yes No
Comments:
Are you experiencing any snoring while wearing a mask? Yes No
Comments:
Do you have issues with dry nose or mouth? Yes No
Comments:
Best way to reach you to resolve problems:
Home Phone
Cell Phone
Email

Mask Fit and Comfort: