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The Sleep Apnea Test (Berlin Questionaire)

The following questionaire is designed to determine your level of risk for sleep apnea. This is not a final diagnosis and we recommend contacting your sleep doctor for a sleep study to provide a thorough diagnosis of sleep apnea.

HeightFeet Inches

WeightLbs

Age

1. Do you snore?

Yes
No
I Don't Know

2. Describe your snoring

I don't snore
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 rarely

4. Has your snoring ever bothered people?

Yes
No
I Don't Know

5. Has anyone ever noticed that you quit breathing during sleep?

Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or rarely

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 rarely

7. When you wake up, 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 rarely

8. Have you ever nodded off or fallen asleep while driving a vehicle?

Yes
No

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 rarely

10. Do you have high blood pressure?

Yes
No
I Don't Know