CPAP Intolerance Assessment Form
Please complete this assessment to help us understand your challenges with CPAP therapy. Your responses will assist in tailoring your treatment for better outcomes.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
How long have you been using CPAP therapy?
*
Please Select
Less than 1 month
1-3 months
3-6 months
6-12 months
More than 1 year
How often do you use your CPAP device?
*
Every night
Most nights (5-6 nights/week)
Some nights (2-4 nights/week)
Rarely (less than 2 nights/week)
Stopped using
Please rate your level of discomfort or difficulty with the following aspects of CPAP therapy:
*
Rows
Not at all
Mild
Moderate
Severe
Very Severe
Mask Fit/Comfort
1
2
3
4
5
Pressure Sensation
6
7
8
9
10
Dryness/Irritation (Nose/Throat)
11
12
13
14
15
Noise from Device
16
17
18
19
20
Skin Irritation/Redness
21
22
23
24
25
Claustrophobia/Anxiety
26
27
28
29
30
What are the main reasons for your intolerance or difficulty with CPAP therapy? (Select all that apply)
*
Mask discomfort
Air leaks
Dry mouth or throat
Nasal congestion
Feeling claustrophobic
Device noise
Difficulty exhaling
Other
How would you rate your overall satisfaction with CPAP therapy?
*
1
2
3
4
5
Have you discussed your CPAP intolerance issues with a healthcare provider?
*
Yes
No
Please provide any additional comments or suggestions regarding your experience with CPAP therapy.
Submit Assessment
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