BiPAP Therapy Assessment Questionnaire

Patient Details

Full Name:

Email Address:

Date of Birth:

Contact Number:

Physical Measurements

Height (cm):

Weight (kg):

BMI (kg/m²):

Neck Circumference (cm):

Cardiovascular History

Do you have any of the following conditions? Heart Failure Atrial Fibrillation Hypertension Coronary Artery Disease Previous Stroke Pacemaker

Please provide details about any selected cardiac conditions:

Neurological Conditions

Do you have any of the following conditions? ALS (Motor Neuron Disease) Muscular Dystrophy Myasthenia Gravis Post-Polio Syndrome Spinal Cord Injury Parkinson's Disease

Please provide details about any selected neurological conditions:

Respiratory Conditions

Do you have any of the following conditions? COPD Asthma Bronchiectasis Recurring Pneumonia Pulmonary Fibrosis Obesity Hypoventilation Syndrome

Sleep Study History

Have you had a sleep study in the past?

Yes No

If yes, please provide details (date, location, results):

Additional Assessment Questions

Since you haven't had a sleep study, please answer these questions to help us better understand your breathing patterns:

How difficult is it for you to breathe out compared to breathing in?

When you breathe, do you notice:

Your abdomen moves inward when you inhale You use neck or shoulder muscles to breathe You need to lean forward to breathe better

When do your breathing difficulties occur?

When lying flat When reclining During physical activity During sleep

Do you experience any of these symptoms in the morning?

Headache Confusion or grogginess Nausea Extremely dry mouth

How would you describe your typical breathing rate?

How many pillows do you use to sleep?

How far can you walk on level ground before becoming short of breath?

Previous PAP Therapy Experience

Have you used any of the following devices? CPAP BiPAP APAP

If you've used any of these devices, please describe your experience:

Current Symptoms

Do you experience any of the following symptoms? Morning Headaches Excessive Daytime Sleepiness Nighttime Breathlessness Waking Up Gasping for Air Night Sweats Difficulty Concentrating Memory Problems Mood Changes/Irritability

Risk Acknowledgment & Disclaimer

Important Notice:

I understand and acknowledge that:

BiPAP therapy should ideally be initiated under medical supervision
A prescription or sleep study results are recommended before starting BiPAP therapy
Using BiPAP without proper medical oversight carries risks
I should seek immediate medical attention if I experience any adverse effects

I acknowledge and accept these risks and understand that I am using this equipment at my own discretion

Digital Signature (Type Full Name):

Date:

Bi Level Therapy Questionnaire