SLEEP DISORDER CENTER
CPAP Follow Up Questionnaire
Fields marked with an asterisk (
*
) are required.
Name:
SPONSOR’S LAST 4:
Age:
Gender:
Male
Female
HEIGHT:
WEIGHT:
CONTACT NUMBER (xxx-xxx-xxxx):
Personal Email:
PLEASE LIST MEDS AND ANY OVER THE COUNTER/SUPPLEMENTS YOU ARE CURRENTLY TAKING:
IS THIS YOUR FIRST APPT AT THE WALTER REED SLEEP DISORDERS CENTER?
Yes
No
DATE OF SLEEP STUDY:
WHERE WAS YOUR FIRST SLEEP STUDY PERFORMED?
HOW LONG HAVE YOU BEEN ON CPAP?
WERE YOU INSTRUCTED TO DO A SLEEP MAPPER REMOTE FOLLOW UP?
Yes
No
IF YES: HAVE YOU DOWNLOADED YOUR CARD?
Yes
No
Once your SD card has been downloaded, please go to our website to schedule a Sleep Mapper
appt. This can be found on the right side of website under "contact us for an appointment.
HAS IT BEEN REPORTED THAT YOU SNORE WHILE USING YOUR CPAP SYSTEM WHEN YOU ARE ASLEEP?
Yes
No
Do Not know
WHAT TYPE OF MASK DO YOU USE:
Select one
Do not know
Full Face
Nasal Pillow (mask with two prongs that go directly in each nostril)
Nasal Mask (mask that covers entire nose but does not cover mouth)
Hybrid
DO YOU WEAR A CHIN STRAP?
Yes
No
ARE YOU EXPERIENCING ANY OF THE FOLLOWING DIFFICULTIES WITH YOUR CPAP OR MASK (check all that apply)?
Difficulty Falling Asleep
Difficulty Staying Asleep
Frequent Awakening
Dry Mouth After Using CPAP
Headaches After Using CPAP
Excessive Burping or
Full Stomach After Using CPAP
Nasal Swelling or Congestion
Difficulty Falling Asleep
Any Equipment Issues
IF YOU HAVE ANY EQUIPMENT ISSUES PLEASE EXPLAIN:
HAVE YOU EXPERIENCED ANY OF THE FOLLOWING SENSATIONS (SIGHT, SMELL, TACTILE, HEARING, OTHER) AFTER USING YOUR CPAP?
Yes
No
IF YES, PLEASE DESCRIBE:
ON THE TYPICAL WORKDAY
When do you go to bed?
How long does it take you to fall asleep?
How many times do you wake at night?
How much time do you spend awake at night?
When do you get out of bed in the morning?
Do you take naps?
Yes
No
If yes: What time do you take your nap/how long?
ON THE TYPICAL NON-WORKDAY
When do you go to bed?
How long does it take you to fall asleep?
How many times do you wake at night?
How much time do you spend awake at night?
When do you get out of bed in the morning?
Do you take naps?
Yes
No
If yes: What time do you take your nap/how long?
QUESTIONS ABOUT YOUR SLEEPINESS (EPWORTH)
How likely are you to doze off or fall asleep on a scale of 0-3?
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting and reading
Select one
0
1
2
3
Watching TV
Select one
0
1
2
3
Sitting inactive in a public place (e.g. a theater or meeting)
Select one
0
1
2
3
As a passenger in a car for an hour without a break
Select one
0
1
2
3
Lying down to rest in the afternoon when circumstances permit
Select one
0
1
2
3
Sitting and talking to someone
Select one
0
1
2
3
In a car stopped for a few minutes in traffic
Select one
0
1
2
3
Sitting quietly after a lunch without alcohol
Select one
0
1
2
3
QUESTIONS RELATED TO YOUR FATIGUE (FOSQ)
Some people have difficulty performing everyday activities when they feel tired or sleepy.
The purpose of below questions is to find out if you generally have difficulty carrying out
certain activities because you are too sleepy or tired. In questions, when the words
“sleepy” or “tired” are used, it means the feeling that you can’t keep your eyes open,
your head is droopy, that you want to “nod off”, or that you feel the urge to take a nap.
These words do not refer to the tired or fatigued feeling you may have after you
have exercised.
1. Do you have difficulty concentrating on the things you do because you are sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
2. Do you generally have difficulty remembering things, because you are sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
3. Do you have difficulty operating a motor vehicle for short distances (less than 100 miles)
because you become sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
4. Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles)
because you become sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
5. Do you have difficulty visiting with your family or friends in their home because
you become sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
6. Has your relationship with family, friends or work colleagues been affected
because you are sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
7. Do you have difficulty watching a movie or videotape because you become sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
8. Do you have difficulty being as active as you want to be in the evening because you are
sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
9. Do you have difficulty being as active as you want to be in the morning because
you are sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
10. Has your desire for intimacy or sex been affected because you are sleepy or tired?
Select one
No difficulty
Yes, a little difficulty
Yes, moderate difficulty
Yes, extreme difficulty
Please use this comment section to let us know anything else about your sleep concerns
that were not mentioned in this Questionnaire OR if you would like to elaborate on any
questions you answered: