Follow-up Visit Questionnaire

Follow-up Visit Form

Must be filled out before the visit
Patient's Full Name*

First NameMiddle NameLast Name
Patient's Date Of Birth*

MonthDayYear
Date
Patient's Date of Visit*

MonthDayYear
Date
What is your height?*
What is your current weight?*
Main reason for follow-up visit*
NoYes
If yes, what is your new insurance carrier name? blanks
What is your insurance ID number? blank
NoYes (Fill out new PCP information below)
New Primary Care Provider Name

First NameLast Name
Primary Care Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Primary Care Provider Address

Street Address

Street Address Line 2

CityState

Zip Code
NoYes (Fill out new dentist information below)
New Dentist Name

First NameLast Name
Dentist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dentist Fax Number
Please enter a valid fax number.Format: (000) 000-0000.
Dentist Address

Street Address

Street Address Line 2

CityState

Zip Code
CPAPOral Appliance (flexTAP, Prosomnus, MAD, etc.)eXcite OSAOtherNone
For CPAP, how many hours a night are you using CPAP?
Name of Oral Appliance:
Are you experiencing any issues/problems with CPAP since last visit?
What is the name and size of mask you are using?
Name of the Durable Medical Equipment (DME) company you got your CPAP from:
Durable Medical Equipment company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

With CPAP, which of the following you have?

Do you still have any of the following symptoms?*

Rows	Yes	No
Loud Snoring
Waking up gasping or choking from sleep
Has anyone noticed that you stopped breathing while sleeping?
Getting up from sleep to urinate multiple times at night
Lack of refreshing sleep upon waking up
Morning Headache
Dry mouth in the morning
Excessive daytime sleepiness
Difficulty falling asleep
Difficulty staying asleep
Attention or concentration problems
Memory loss
Heartburn or acid reflux
Nasal congestion
If female, decreased libido. If male, erectile dysfunction.
Feeling drowsy while driving
Have you had any motor vehicle accidents or near accidents due to drowsiness?

List other issues you have been experiencing if not listed above.
YesNo
If yes, what are your new medications? blanks blank
Sleep Schedule
Current Bedtime Time (Weekday):*

Hour Minutes

AM/PM Option
Current Wake Up Time (Weekday):*

Hour Minutes

AM/PM Option
How much time do you take to fall asleep?*
15 mins, 30 mins, etc.
How many hours do you sleep every night? *
Total number of hours your body requires to feel refreshed:*
Is your sleep schedule different on weekend: *
Current Bedtime Time (Weekend):

Hour Minutes

AM/PM Option
Current Wake Up Time (Weekend):

Hour Minutes

AM/PM Option
YesNo
How many times do you wake up every night and why? *
YesNo
If yes, how many naps do you take in a day? blanks
How long is each nap? blank.
What is your preferred sleeping position?*
e.g. Flat, side-lying, etc.
Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

No Chance = 0 Slight Chance = 1 Moderate Chance = 2 High Chance = 3

Rows	CHANCE OF DOZING (0-3)
Sitting and Reading
Watching TV
Sitting inactive in a public place (e.g., a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Follow-up Visit Form