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)
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