BERLIN QUESTIONNAIRE
(for sleep apnea)         

Positive Categories
Result
Name Weight kg pounds 
Age             Male          Female Height cm in
Category 1.    points

1. Do you snore?
a. Yes
b. No
c. Don't Know

 If you snore

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

3. How often do you snore?
a. Nearly every day
b. 3 to 4 times a week
c. 1 to 2 times a week
d. 1-2 times a month
e. Never or nearly never

4. Has your snoring ever bothered other people?
a. Yes
b. No
c. Don't know

5 Has anyone noticed that you quit breathing during your sleep?
a. Nearly every day
b. 3 to 4 times a week
c. 1 to 2 times a week
d. 1 to 2 times a month
e. Never or nearly never

Javascript Copyright 2012 by Focus Information Technology. All rights reserved.

Category 2     points

6. How often do you fell tired or fatigued after your sleep?
a.  Nearly every day
b.  3 to 4 times a week
c.  1 to 2 times a week
d.  1 to 2 times a month1
e.  Never or nearly never

7. During your waking time, do you feel tired, fatigued or not up to par?
a.  Nearly every day
b. 3 to 4 times a week

c. 1 to 2 times a week
d. 1 to 2 times a month\
e. Never or nearly never

8. Have you ever nodded off or fallen asleep while driving a vehicle?
a. Yes
b. No

If Yes :

9. How often does this occur?
a. Nearly every day
b. 3 to 4 times a week
c. 1 to 2 times a week
d. 1 to 2 times a month
e. Never or nearly never.
 
Category 3   points

10. Do you have high blood pressure?
Yes
No
Don't Know
Body mass index (kg/m2) =