CPAP-Questionnaire

Get help at no cost: Fill out the form below to see if you are eligible to join. If you qualify, an attorney will contact you to discuss the details of your potential case at no charge to you.

Name *

First

Middle

Last

Phone

Email *

Address

Address Line 1

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City

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Zip Code

Best time to contact you? time7am-9am9am-12pm12pm-5pm5pm-7pm7pm-12am

Did you use a Philips CPAP device? *YesNo

When did you first begin using the Philips CPAP device?

What is the last date that you used the Philips CPAP device?

How long did you use the Philips device for?

How often did you use the Philips device for?

For what reason were you prescribed the Philips CPAP device?

Have you purchased a replacement machine? *YesNo

Have you been diagnosed with cancer? *YesNo

Have you been diagnosed with any of the following ailments?Have you been diagnosed with any of the following ailments?Heart attack or heart failureStrokeRespiratory FailureLiver DiseaseKidney Disease

Have you experienced any of the following symptoms?Have you experienced any of the following symptoms?Upper airway irritationHeadachesInflammation of the lungsRespiratory issues such as asthmaIrritation of the skin/eyes or respiratory tractAdverse effects to the liver or kidneysHypersensitivityNausea/vomitingChest pressureSinus Infection

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