Berlin Questionnaire

Fill Out The Berlin Questionnaire Below

Leave this empty

Patient's Full Name: *FirstLast

Age *

Sex *

Height ft/in (example: 5' 8") *

Weight in lbs *

Do you sleep with a bed partner? * Yes No

Category 1 Please choose the correct response to each question.

1. Do you snore? * A: Yes B: No C: Don't Know

2. Your snoring is...? * A: Slightly louder than breathing B: As loud as talking C: Louder than talking D: Very loud - can be heard in adjacent rooms E: Don't Know

3. How often do you snore? * A: Nearly everyday B: 3-4 times a week C: 1-2 times a week D: 1-2 times a month E: Never or nearly never F: Don't Know

4. Has your snoring ever bothered other people? * A: Yes B: No C: Don't Know

5. Has anyone ever noticed that you quit breathing during your sleep? * A: Nearly everyday B: 3-4 times a week C: 1-2 times a week D: 1-2 times a month E: Never or nearly never F: Don't Know

Category 2 Please choose the correct response to each question.

6. How often do you feel tired or fatigued after your sleep? * A: Nearly everyday B: 3-4 times a week C: 1-2 times a week D: 1-2 times a month E: Never or nearly never F: Don't Know

7. During your waking time, do you feel tired, fatigued, or not up to par? * A: Nearly everyday B: 3-4 times a week C: 1-2 times a week D: 1-2 times a month E: Never or nearly never F: Don't Know

8. Have you ever nodded off or fallen asleep while driving a vehicle? * A: Yes B: No C: Don't Know

IF YES... 9. How often does this occur? A: Nearly everyday B: 3-4 times a week C: 1-2 times a week D: 1-2 times a month E: Nearly never F: Don't Know

10. Do you have high blood pressure? * A: Yes B: No C: Don't Know

Digital Signature of Consent * By checking this box, I am providing a digital signature of consent to all the information provided.

What is 6 + 6? *

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