Facebook

Patient Follow-Up Questionnaire

2-Week Follow-Up Date:
  
Patient's Name:
Phone Number:
Referring Physician:
Final Study Treatment:
  
  
1. Did you receive your test results from your physician? Yes     No
Comments:

2. Did you Schedule a follow-up appointment with you physician? Yes     No
Comments:

3. Have you been set up with a CPAP machine? Yes     No
Comments:

4. Are you still tired? Yes     No
Comments:

5. How is your energy level? Yes     No
Comments:


Other Comments
Clear Send