Post Therapy Trial Questionnaire

Patient Name

Title

First name

Middle name

Surname

Maiden name (if applicable)

Date of Birth (DD/MM/YYYY)

CPAP Therapy Questions

What difficulties have you experienced with your therapy?

Mask comfort:

Pressure:

Nose Soreness:

Throat Dryness:

Other (Please describe):

Provent Therapy Questions

What difficulties have you experienced with your therapy?

Nasal Valve Seal:

Nasal Valve Comfort:

Ease of Exhalation:

Nostril Soreness:

Other:

Patient Epworth Sleepiness Scale

Note: This is to be completed by the patient, about themselves.

In the following situations, please choose how likely you are to doze or fall asleep by selecting the most applicable box:

	Never Doze/Not Applicable	Slight Chance of Dozing	Moderate Chance of dozing	High Chance of Dozing
1. Sitting and Reading
2. Watching TV
3. Sitting quietly in a public place (e.g. meeting or theatre)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon, when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after lunch without alcohol
8. In a car, while stopped for a few minutes in traffic

Patient Epworth Score:

Major Depression Index [MDI]

The following questions ask about how you have been feeling over the last two weeks. Please mark the box which is closest to how you have been feeling.

	None of the time	Some of the time	Less than half of the time	More than half of the time	Most of the time	All of the time
1. Have you felt low in spirits or sad?
2. Have you lost interest in your daily activities
3. Have you felt lacking in energy or strength?
4. Have you felt less self-confident
5. Have you had a bad conscience or feelings of guilt?
6. Have you felt that life isn't worth living?
7. Have you had difficulty in concentrating?
8a. Have you felt very restless?
8b. Have you felt subdued
9. Have you had trouble sleeping at night?
10a. Have you suffered from reduced appetite?
10b. Have you suffered from increased appetite?

Patient Major Depression Index:

Insomnia Severity Index (ISI)

For each question, please rate the current severity of your sleep problem by selecting the most appropriate response from the drop down list.

Please rate the severity of your difficulty in falling asleep:

Please rate the severity of your difficulty in staying asleep:

Please rate your problem waking up too early in the morning:

Please rate how SATISFIED you are with your current sleep pattern:

Please rate how your sleep problem INTERFERES with your daily functioning, i.e. daytime fatigue, concentration, mood, ability to function at work, ability to complete tasks at home, etc:

Please rate the extent to which your sleep problem is NOTICEABLE to others:

How WORRIED/DISTRESSED are you about your current sleep problem:

Insomnia Severity Index (ISI):

Contact Information