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ResMed Tango CPAP**:
**Record the number on the machine when you turn it on.
Hours read:
Respironics Remstar/Remstar Plus M Series***:
***Press the back arrow and record the information above. You will need to continue pressing the back arrow until all information is recorded.
Therapy Usage (hrs/night)
7 day average:
30 day average:
Sessions > 4
7 day average:
30 day average:
Compliance Check#:
Number:
Summary Data:
Therapy Hours:
Blower Hours:
Total Sessions:
2. Please complete all of the following:
First & Last Name:
Equipment Use:
YesNo Mask fitting / no leaks
YesNo Nocturnal use hours per night
YesNo Cleaning of equipment
YesNo Filters changed/washed
YesNo Supply of backup equipment (i.e. mask/tubing/headgear)
Symptomology:
YesNo Decreased daytime sleepiness
YesNo Adequate humidity
YesNo Complaint of skin, eye, nose or throat irritation
YesNo Weight change
YesNo Improved quality of sleep
YesNo Increase in energy level
Comments
Thank you for assisting us in obtaining the information required by your physician/insurance company. If you have any questions or issues with your CPAP machine, please do not hesitate to call us at (704) 846-7503.
You may be eligible for supplies. Please contact our office to advise if you would like the supplies to be sent to you.
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