Patient Care Survey


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First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
City:
State/Province
(US/Canada):

Order Number

 

50 characters left.


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 have had no alcohol)  
In a car while stopped in traffic  


Do you feel your CPAP / BiPAP helps?

Yes
No
  • Comment:

  • 500 characters left.

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

 

50 characters left.


Who was your Patient Care Technician / Customer Service Representative?

 

50 characters left.

Did the Customer Service Representative explain to you the CPAP / BiPAP supply replacement schedule?

Yes
No
  • Comment:

  • 500 characters left.


How often do you replace your CPAP / BiPAP supplies?

Every month
Every 3 months
Every 6 months
Every Year
Never
Other  

How would you rate your level of satisfaction with our services?

Highly satisfied Somewhat satisfied Neutral Somewhat dissatisfied Highly dissatisfied       
      
  • Comment:

  • 500 characters left.


Did you receive all the products as you requested?

Yes
No
  • Comment:

  • 500 characters left.


Please share any suggestions for improving our patient care services.

 

350 characters left.


Thank you for taking the time to complete our survey online.