Obstructive Sleep Apnea/CPAP Follow-up

*** Please fill out this form in full, to the best of your knowledge


How your CPAP has effected your sleep
Check one



What type of mask do you wear?

Do you use your CPAP every night?

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

Do you use your CPAP during ALL naps?

Does anyone report that you snore while wearing CPAP?

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

       If so, how often does this occur?

While using CPAP, do you wake up with a dry mouth?

     If yes, how often does this occur?

Do you suffer from nighttime nasal congestion?


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            

Watching TV

Sitting, inactive in a public place (e.g. theater or a meeting)

As a passenger in a car for an hour without a break           

Lying down to rest in the afternoon when circumstances permit          

Sitting and talking to someone            

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in the traffic