Berlin Questionnaire
Sleep Apnea
Height :  ft.    inches   Weight:  kg.
Age: Male / Female:
Please choose the correct response to each question.
Category 1


1. Do You snore?



If you answered 'yes'

2. You snoring is:





3. How often do you snore?






4. Has your snoring ever bothered other people?




5. Has anyone noticed that you stop breathing during your sleep?







Category 2


6. How often do you feel tired or fatigued after your sleep?





7. During your waketime, do you feel tired, fatigued or not up to par?





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


If you answered 'yes'

9. How often does this occur?






Category 3


10.
Do you have high blood pressure?




Name *:
Contact No.* :
Email * :
Address :
Report
Your Total Score is   ( Label  )
Your BMI is  ( Label  )