affidavit for intolerance to CPAP
For Patient:
First Name:
Last Name:
I have attempted to use the nasal CPAP to manage my sleep related breathing disorder (apnea) and find it intolerable to use on a regular basis for the following reason(s) (Please check all that apply):
Mask Leaks
An Inability to fit the mask to Fit Properly
Discomfort caused by Straps and Headgear
Disturbed or Interupted Sleep Caused by the Presence of the Device
Noise From the Device Disturbing Sleep or Bed/Partner's Sleep
CPAP Restricted Movements During Sleep
CPAP Does Not Seem To Be Effective
Pressure On The Upper Lip Causes Tooth Related Problems
Latex Allergy
Claustrophobic Associations
An Unconscious Need to Remove the CPAP Apparatus at Night
Other
Because of my intolerance/inability to use the CPAP, I wish to have an alternative method of treatment.
That form of therapy is oral appliance therapy (OAT).
Patient/Responsible Party: