Sleep Well Centers Patient Follow Up:

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Patient Name
Patient E-mail Address
Primary Care Physician
Current Treatment CPAP Bilevel Dental Appliance
How many hours a night are you using therapy? 1-3 4-6 7+
Who is your Home Care Provider? Shamrock Respiratory Services N/A
Other Home Care Provider
Are you receiving periodic contact from your Home Care Provider? Yes No
Have you had any of the following Surgeries since your last Sleep Study? UVPPP Bariatric N/A
Other Surgeries
Have you experienced weight loss or weight gain since the start of your therapy? Yes No
If gain, how much?
If loss, how much?
Please check all that apply Daytime Sleepiness Taking Naps Distention Headaches Excess nasal dryness Snoring Sleepiness while driving Memory Loss Machine not working/Supply issue No improvement seen
Patient comments/questions
Technician summary: (To be completed by Clinical Liaison)