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510-845-3295

2999 Regent Street, Suite 727

Berkeley, CA 94705 USA

Berlin Questionnaire

 

Category 1

 

Do you snore?

___ Yes

___ No

___ Don’t Know

 

Your snoring is?

___ Slightly louder than breathing

___ As loud as breathing

___ Louder than talking

___ Can be heard in adjacent room

 

Describe the snoring frequency

___ Nearly every day

___ 3-4 times a week

___ 1-2 times a week

___1-2 times a month

___ Never or nearly ever

 

Has your snoring ever bothered other people?

___ Yes

___ No

 

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

How often do you feel tired or fatigued after you sleep?

___ Nearly every day

___ 3-4 times a week

___ 1-2 times a week

___ 1-2 times a month

___ Never or nearly never

 

During your wake 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

 

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

___ Yes

___ No

 

If yes, 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

Do you have high blood pressure?

___ Yes

___ No

 

BMI= mass (kg) / (height (M))2  = mass (lbs) / (height (inches))2 x 703 =_______________

 

 

Category 1 positive (>2)   ______

Category 2 positive (>2)   ______

Category 3 positive (1 or BMI > 30) ______

 

HIGH RISK  if there are 2 or more Categories where the score is positive

LOW RISK  if there are one or no Categories where the score is positive

 

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8:00 AM-5:00 PM

Tuesday:

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Wednesday:

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Thursday:

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