Home Therapy Equipment CPAP/BIPAP Follow-up

4 Enterprise Avenue Clifton Park, New York 12065 518-664-6654


CPAP/BIPAP Use

Number of hours user per night (on average):

Number of days used per week:

Are you cleaning equipment with mild soap and water?	Yes	No

Are you washing and or changing pollen filters on a regular basis?	Yes	No

What is your pressure setting?

Have you had any weight gain/loss since you start therapy?	Yes	No

Patient Reports


Has therapy made a difference in lifestyle/energy level?	Major Noticeable Little None Unsure

Are you drowsy while driving?	Yes	No

Do you have recurring headaches in the AM?	Yes	No

Do you snore?	Yes	No

Are you having any mask problems?	Nasal discomfort Bridge of nose discomfort Upper lip discomfort Leaking; if so, where? None

Are you having any other problems with the mask?

Are you waking up frequently during the night?	Yes	No

Are you taking the mask off in your sleep?	Yes	No

Are you using a humidifier?	Yes	No
If yes, what type are you using?	Cool	Heated

Has anyone adjusted the settings on your CPAP/BIPAP?	Yes	No

Do you plan on continuing using CPAP/BIPAP in the future?	Yes	No

Are there any other problems?

Comments or suggestions?