Patient Care Survey
Progress: 
 
1.

Order Number
 

  • 50 characters left.
2.

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.
 Never Slight chance Moderate chance High chance  
Sitting and reading  
Watching television  
Sitting inactive in a public place (for example, a theater or meeting)  
As a passenger in a car for an hour without a break  
Lying down to rest in the afternoon  
Sitting and talking to someone  
Sitting quietly after lunch (when you've had no alcohol)  
In a car while stopped in traffic  
3.

Do you feel your CPAP / BIPAP helps?
Yes
No
  • Comment:

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4.

How many hours per night do you use your CPAP / BiPAP?
 

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