SLEEP APNEA MASK QUESTIONAIRE

Stellar Pharmacy | CPAP Mask & Setup Questionnaire CPAP Mask & Setup Questionnaire Stellar Pharmacy Complete this form before your CPAP consultation. Your answers help us identify the most suitable mask style and prepare your setup in advance. Full name Email address 1. Have you been diagnosed with sleep apnoea by a doctor or sleep study? Yes No Not sure 2. Have you been given CPAP pressure settings? Yes No Not sure 3. Is this your first time using a CPAP machine? Yes No Not sure 4. When you sleep, do you mostly breathe through your: Nose Mouth Not sure 5. Do you often experience a blocked or congested nose at night? Yes No Sometimes 6. Do you wake up with a dry mouth? Yes No Sometimes 7. Do you think your mouth opens while you sleep? Yes No Not sure 8. Which type of mask would you prefer? Minimal and lightweight Moderate coverage (nose only) Full coverage (nose and mouth) Not sure 9. Do you feel uncomfortable or claustrophobic with something covering your face? Yes No A little 10. What is your usual sleeping position? Back Side Stomach I move around a lot 11. Have you used a CPAP mask before? No Yes Not sure 12. Are you sensitive to strong airflow or pressure? Yes No Not sure 13. Do you have any implanted medical devices or metal fragments near the head or chest? Examples: pacemaker, ICD, neurostimulator, insulin pump, cochlear implant, shunt, aneurysm clip, metallic eye fragment. Yes No Not sure 14. Do you have facial sensitivities, skin concerns, or previous mask-fit issues? Yes No Not sure 15. Is there anything else you would like us to know to improve your comfort? Get My Mask Recommendation Reset Form Important: This recommendation is a pre-screening guide only. Final mask selection should always be confirmed by an in-person fitting with the machine running. Prepared for Stellar Pharmacy. This form can be embedded on a website or rebuilt in Google Forms using the same questions and logic.