Dot Tracking Flow Sheet

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LABEL
LEGEND
PSG = Polysomnogram
DOT – TRACKING FLOW SHEET
EF = Ejection Fraction
AHI = Apnea Hypopnea Index
Required
DX = Diagnostic
Lenses
Date ___________
Hearing Aid Date ____________
Comments: _________________________________
___________________________________________
Employer: __________________________________
DATE
PSG
COMPLIANCE
HgB A1C
Dx Eye Exam
Stress Test or Echo
BP
Card Exp
Comments
DOWNLOAD
Date/Value
Date
Result
EF
Date
Date
% Use
Avg. # hrs.
AHI
Date
% Use
Avg. # hrs.
AHI
Date
% Use
Avg. # hrs.
AHI
Date
% Use
Avg. # hrs.
AHI
Date
% Use
Avg. # hrs.
AHI
Date
% Use
Avg. # hrs.
AHI
Date
% Use
Avg. # hrs.
AHI
Date
% Use
Avg. # hrs.
AHI

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