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Patient - CPAP Therapy Survey

 

*

1. I was prescribed CPAP Therapy at a:

I was prescribed CPAP Therapy at a:   Hospital Hospital Sleep Lab Private Sleep Lab Family Physician

Other Comments

2. A CPAP company was recommended by:

A CPAP company was recommended by:   My Own Research Sleep Physician Respirologist Other Specialist Family Physician Sleep Lab Staff Other (see comments)

Other (please specify)

3. I am:

I am:   Male Female

4. My age is:

My age is:   < 40 40 - 50 50 - 60 60 - 70 > 70

5. I live in the following Province

I live in the following Province   BC AB SK MB ON QC NB NS PEI NL

6. I am currently:

I am currently:   Working full time Working part time Unemployed Retired Other

Other (please specify)

7. I choose VitalAire because:

I choose VitalAire because:   Convenience to Sleep Lab (Hospital/Clinic) Convenience to my home Healthcare staff recommendation Recommendatioin from friend/family

Other (please specify)

8. Please rate the importance of the following to the success of your CPAP therapy:

	Not Important	Somewhat Important	Neutral	Very Important	Extremely Important
Range of CPAP products offered	*Please rate the importance of the following to the success of your CPAP therapy: Range of CPAP products offered Not Important	Range of CPAP products offered Somewhat Important	Range of CPAP products offered Neutral	Range of CPAP products offered Very Important	Range of CPAP products offered Extremely Important
Ease of contact and response time	Ease of contact and response time Not Important	Ease of contact and response time Somewhat Important	Ease of contact and response time Neutral	Ease of contact and response time Very Important	Ease of contact and response time Extremely Important
Optimizing comfort (mask fitting)	Optimizing comfort (mask fitting) Not Important	Optimizing comfort (mask fitting) Somewhat Important	Optimizing comfort (mask fitting) Neutral	Optimizing comfort (mask fitting) Very Important	Optimizing comfort (mask fitting) Extremely Important
Educational materials including operating instructions, hygiene and safety	Educational materials including operating instructions, hygiene and safety Not Important	Educational materials including operating instructions, hygiene and safety Somewhat Important	Educational materials including operating instructions, hygiene and safety Neutral	Educational materials including operating instructions, hygiene and safety Very Important	Educational materials including operating instructions, hygiene and safety Extremely Important
The importance of treatment, benefits of CPAP	The importance of treatment, benefits of CPAP Not Important	The importance of treatment, benefits of CPAP Somewhat Important	The importance of treatment, benefits of CPAP Neutral	The importance of treatment, benefits of CPAP Very Important	The importance of treatment, benefits of CPAP Extremely Important
Access to professional staff	Access to professional staff Not Important	Access to professional staff Somewhat Important	Access to professional staff Neutral	Access to professional staff Very Important	Access to professional staff Extremely Important
Active follow-up to improve my therapy (6 month follow up)	Active follow-up to improve my therapy (6 month follow up) Not Important	Active follow-up to improve my therapy (6 month follow up) Somewhat Important	Active follow-up to improve my therapy (6 month follow up) Neutral	Active follow-up to improve my therapy (6 month follow up) Very Important	Active follow-up to improve my therapy (6 month follow up) Extremely Important
Sending reports back to my Physician	Sending reports back to my Physician Not Important	Sending reports back to my Physician Somewhat Important	Sending reports back to my Physician Neutral	Sending reports back to my Physician Very Important	Sending reports back to my Physician Extremely Important

Other (please specify)

9. I am on CPAP Therapy:

	YES	NO
I would like to be contacted every 6 months and reminded to replace my mask	*I am on CPAP Therapy: I would like to be contacted every 6 months and reminded to replace my mask YES	I would like to be contacted every 6 months and reminded to replace my mask NO
I would subscribe to an on-line CPAP Therapy Newsletter	I would subscribe to an on-line CPAP Therapy Newsletter YES	I would subscribe to an on-line CPAP Therapy Newsletter NO
I would like to regularly receive information on new CPAP Therapy products	I would like to regularly receive information on new CPAP Therapy products YES	I would like to regularly receive information on new CPAP Therapy products NO

Other (please specify)