Customer Evaluation - Local Locker CPAP

Atlanta 404-220-7635 ☎ Orlando 407-270-0140

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STEP: 1
PATIENT QUESTIONNAIRE

Thank you for choosing eSNORE & SLEEP for your Home Sleep Test. Please take a few minutes to fill out this questionnaire.

Patient Demographics

* Indicates required field

Select One *

Name *

First

Last

D.O.B. *

Mobile Number *

Home Number *

Gender *

Email *

Can we send you a text? *

No Yes Yes, As the last option Yes, It's prefered

Choose each method

Address *

Line 1

Line 2

City

State

Zip Code

Country

Your Health History

Height *

Approximate Weight *

Currently using CPAP? *

Yes No

Currently on Oxygen? *

Yes No

Check all symptoms that apply: *

Daytime Sleepiness/Napping Fatigue Hypertension Irritability/Moodiness Morning Headached Previous Diagnosis of OSA Shift Work Witnessed Apneic Events Witnessed Choking/Gasping During Sleep Witnessed Snoring NONE

Check all situations that apply *

Assessment of efficacy of CPAP/Any PAP Therapy Assessment of efficacy of Oral Appliance Therapy Assessment of efficacy of Surgery Assessment of efficacy of other treatment Re-evaluation of OSA is needed to continue therapy Other NONE

Other *

Previously Diagnosed:

Choose Any *

Atrial Fibrillation Congestive Heart Failure COPD Coronary Artery Disease Diabetes GERD Hypertension Movement Disorder/Bruxism Obestity Seizure within the last 12 months Stroke/TIA OTHER NONE

Please list Other Ailments (Type N/A if none) *

Medications *

Benzodiazepines Narcotics Other Hypnotics N/A

Sleep Assesment

I have had a Sleep Study before *

No Tried, but could not complete it Yes, less than 2 years ago Yes, more than 2 years ago

I have tried CPAP before *

Never Tried, but could not tolerate it I am currently using CPAP

I wake with dry mouth or throat *

Never Occasionally Frequently Every Day

I wake up in the middle of the night *

Never Occasionally Frequently Every Night

I usually wake up to urinate *

Never Once Twice Three or more times

At night, I usually wake up *

Almost never Once a night Several times a night More than 3 times a night

Epworth Sleepiness Scale:

Do you get sleepy, or doze off while sitting & reading? *

Never doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

Do you get sleepy, or doze off while watching TV? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

While sitting or inactive in a public place (meeting, theater)? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

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

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

Lying down to rest in the afternoon? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

Sitting and talking to someone? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

Sitting quietly after lunch without alcohol? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

In a car, while stopped for a few minutes at a traffic light? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

STEP 2:
Scheduling a call back from an eSNORE & SLEEP technician

Thank you for completing our questionnaire. A technician will contact you to review this questionnaire and discuss the next steps in the process.
Please indicate which day that you are available for a brief call, and choose a one hour window when the technician can contact you.
For example: (Tomorrow or 2 Days From Now) and (9:00 am to 10:00 am).

Best day to review this questionnaire? *

Best time to reach you on that day *

Submit

Contact us

Local CPAP Express - NYC
469 7th Avenue, New York, NY 10018
Office: 646-762-8787
Fax 877-342-6484
☎ 646-762-8787
✉ info@localcpap.com

Google Plus Sleep Apnea CPAP Store Alpharetta Atlanta Cumming GA

Authorized Dealers for:

✔ Fisher & Paykel
✔ Phillips Respironics
✔ Portable Outlet
✔ ResMed
✔ SoClean
✔ Somnetics/Transcend
✔ 3B Products/Luna/RESmart

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