Berlin Questionnaire

Fill Out The Berlin Questionnaire Below

Patient's Full Name:*
First Middle Last
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.
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Fill Out The Berlin Questionnaire Below

Category 1

Category 2

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