Florida Sleep Disorder Center - Florida Sleep, Sleep Disorders, Sleep Apnea, Sleep Medicine, and Pulmonology Sleep Disorder Center in Florida

BERLIN QUESTIONNAIRE

General Information
Height (in): *
Weight (lbs): *
Age: *
Sex: *	Male Female
Please choose the correct response to each question.
Category 1
1. Do you snore? *	Yes No Don't know
If you snore:
2. Your snoring is:	Slightly louder than breathing As loud as talking Louder than talking Very loud - can be heard in adjacent rooms
3. How often do you snore?	Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
4. Has your snoring ever bothered other people?	Yes No Don't know
5. Has anyone noticed that you quit breathing during your sleep? *	Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
Category 2
6. How often do you feel tired or fatigued after your sleep? *	Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
7. During your waking time, do you feel tired, fatigued or not up to par? *	Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
8. Have you ever nodded off or fallen asleep while driving a vehicle? *	Yes No
If yes:
9. How often does this occur?	Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
Category 3
10. Do you have high blood pressure? *	Yes No Don't know
*Indicates a required field.

This Sleep Questionnaire is not intended to replace a consulation with a physician regarding your medical care.

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