Affidavit for Intolerance or Non-Compliance to CPAP
Patient Name
First Name
Last Name
Type a question
Yes
No
I have discussed CPAP with my physician and am refusing CPAP at this time.
I am not able to try and tolerate CPAP treatment at this time.
I prefer oral appliance VS CPAP if I am diagnosed with sleep apnea.
I have attempted to use CPAP (Continuous Positive Air Pressure) to manage my sleep related breathing disorder.
I prefer to use the oral appliance in combination with my CPAP to lower the pressure setting on my CPAP.
PLEASE SEE FOLLOWING REASONS FOR INTOLERANCE OR NON-COMPLIANCE
Type a question
I cannot tolerate anything on face due to claustrophobia when sleeping.
An inability to get the mask to fit properly
Discomfort caused by the straps and headgear
Disturbed or interrupted sleep caused by the presence of the device and most likely wouldn't be able to keep it on.
Noise from the device disturbing sleep or bed partner's sleep
CPAP restricted movements during sleep
CPAP does not seem to be effective
Pressure on the upper lip causes tooth related problems
Cpap caused distended stomach, burping and/or irritated IBS symptoms.
CPAP has caused lack of intimacy in my relationship.
Difficulties sleeping after removing/replacing cpap after having to go to the bathroom
Latex Allergy
No electricity for usage of CPAP
I have attempted the following due to my sleep apnea/snoring:
Nasal Strips
Nose cones
Positional Therapy (Changing positions while sleeping)
Dieting/Weight loss
Because of my intolerance and/or inability to use or try the CPAP or because I am refusing CPAP, I wish to have my OSA treated by Oral Appliance Therapy utilizing a custom fitted Mandibular Advancement Device.
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Month
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Day
Year
Date
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