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: