Portable Oxygen Concentrator Questionnaire

Portable Oxygen Concentrator Questionnaire

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Please answer the following questions to help us evaluate your oxygen needs

The answers to the following questions will provide our Licensed Respiratory Therapists information to help determine which POC device will best meet your specific needs.

Once we receive your completed questionnaire, we will evaluate the information you have provided. A therapist will then contact you by telephone within 24 hours.

If you prefer, you may also contact us to complete the questionnaire, by telephone, fax or in person.

Your Information...

* Required Entries

Name*

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Street

City*

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State*

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Phone Number*

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eMail Address*

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Questionnaire...

1. The Diagnosis for which you were prescribed oxygen

2. Your Prescribed Liter Flow is

3. Have you ever used an "On Demand/Pulse Oxygen Flow Device"?	Yes No
4. If yes, please provide the brand of the device
5. Have you ever been told you must use "continuous flow" only?	Yes No
6. Have you ever had a "night Oxygen Saturation test" performed?	Yes No
7. Do you use CPAP ; BiPAP ; or any other Respiratory Assist device?	Yes No
8. Have you ever been diagnosed or told you have Sleep Apnea?	Yes No
9. Have you ever had any part of your lung removed for any reason?	Yes No
10. Do you have an artificial Airway; "Tracheotomy Tube" in place?	Yes No


Your Comments or Questions... Please add your comments or questions if you have any ...


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When ready, please click to submit your questionnaire.

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Portable Oxygen Concentrator Questionnaire

Please answer the following questions to help us evaluate your oxygen needs

Your Information...

Questionnaire...

Your Comments or Questions...