SoFHA
Patient Forms

Annual PAP Follow Up


Description:

The SoFHA Sleep Center Annual PAP Follow Up paperwork.


Code:

9.106

Issued:

12/19/2019

Revision:

1

Revised:

N/A

It is important that you fill out this sleep questionnaire completely and as accurately as possible. Please answer each question. The questionnaire is a broad-based screening tool that will assist our staff and your treating sleep physician to provide excellent care to you. It may be helpful to consult with a family member or bed partner when answering these questions. All information contained in this questionnaire will become a part of your medical record and will be confidential.

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Notice of Nondiscrimination

Interpreter Services


Patient Information



















Insured Information







Physician Information









Sleep Schedule




Weekday






Weekend










What wakes you from your sleep?




Epworth Sleepiness Scale

Please estimate your risk of falling asleep in the following situations.


PAP Treatment


Pap Benefits


Reasons for Limited Use


Current Symptoms


Current Medications





Signature

By typing your name in the signature fields below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.