Insurance Program - LOCAL CPAP EXPRESS DC

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Patient Demographics

* Indicates required field

Name *

First

Last

Gender *

D.O.B. *

Mobile Number *

Home Number *

Email *

Address *

City *

State *

Zip Code *

Insurance Information

Insurance Company *

Phone Number *

Untitled *

Untitled *

Your Health History

Height *

Approximate Weight *

Please check if you have any of the following *

High Blood Pressure Heart Disease Pulmonary Disease Insomnia Overweight Diabetes Frequent Urination at Night Seizure Disorder Other NONE

Please describe any other ailments not listed (or type "none") *

Please list any surgeries you may have had (or type "none") *

Sleep Assesment

I have been told that I snore *

Yes No Don't Know

I have had a Sleep Study before *

No Tried, but could not complete it Yes, less than 2 years ago Yes, more than 2 years ago

I have tried CPAP before *

Never Tried but could not tolerate it Tried and want to own one I am currently using CPAP

I wake up in the middle of the night *

Never Occasionally Frequently Every Night

I usually wake up to urinate *

Never Once Twice Three or more times

I wake with dry mouth or throat *

Never Occasionally Frequently Every Day

Epworth Sleepiness Scale:

Do you get sleepy, or doze off while sitting & reading? *

Never doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

Do you get sleepy, or doze off while watching TV? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

While sitting or inactive in a public place (meeting, theater)? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

As a passenger in a car for an hour without a break? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

Lying down to rest in the afternoon? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

Sitting and talking to someone? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

Sitting quietly after lunch without alcohol? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

In a car, while stopped for a few minutes at a traffic light? *

Never would doze off Slight Chance of dozing Moderate Chance of dozing High Chance of dozing

Submit

Contact us

Local CPAP Express - D.C.
1629 K Street NW #320, Washington, DC 20006
☎ 202-503-2706
Fax 877-342-6484
✉ [email protected]

Google Plus Sleep Apnea CPAP Store Alpharetta Atlanta Cumming GA

Authorized Dealers for:

✔ Fisher & Paykel
✔ PAP Clean
✔ Phillips Respironics
✔ Portable Outlet
✔ ResMed
✔ Z2/Breas

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