CPAP Affadavit

Affadavit for Intolerance to Positive Airway Pressure (PAP) Device

Please correct the errors described below.

I HAVE ATTEMPTED to use Positive Air Pressure CPAP, APAP, etc to manage my Obstructive Sleep Apnea & find it intolerable to use on a regular basis for the following reason(s):

Check all that apply:

Mask Leaks

An inability to get mask to fit properly

Discomfort caused by the straps and headgear

Disturbed or interruped sleep caused by the presence of device

Noise from the device disturbing sleep or bed partner’s sleep

CPAP restricts movements during sleep

CPAP does not seem to be effective

Pressure on upper lip causes tooth-related problems

Latex allergy

Claustrophobic associations

An unconscious need to remove the CPAP apparatus at night

CPAP use caused GI / stomach / intestinal problems

CPAP irritated my nasal passages or sinuses

CPAP irritated the skin on my nose and face

Causes a dry nose or dry mouth

Causes eye irritation due to air leaks

Other

Please describe:

I HAVE NOT ATTEMPTED to use Positive Air Pressure CPAP, APAP, etc. (Continues Positive Air Pressure) device and would prefer to use an oral applience for the following reason(s):

Check all that apply:

I’m worried that mask, straps/headgear will cause discomfort

I’m worried that noise from the device will disturb me and/or my bed partner’s sleep I’m

Worried that the device will restrict movement during sleep

I have latex allergy

I suffer from claustrophobia

I travel frequently and worried that a CPAP device will be cumbersome to transport

Other

Please describe:

Because of my inability to use a CPAP device, I wish to have an alternative method of treatment. I would like to try an oral appliance to control my snoring and obstructive sleep apnea.

Patient's Full Name

Today's Date

Legal Guardian's Full Name (if patient is a minor)

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Center for TMJ & Sleep Solutions NW

BOARD CERTIFIED OROFACIAL PAIN AND DENTAL SLEEP MEDICINE DOCTORS

Silverdale: 360-979-1537, Federal Way: 253-352-4430, Lynnwood: 425-584-5924
tmjsleepsolutionsnw.com
10513 Silverdale Way NW Suite 201, Silverdale, WA, 98383
32114 1st Ave S Suite 104, Federal Way, WA, 98003
19106 33rd Ave W, Suite 2, Lynnwood, WA, 98036

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