Berlin Questionnaire

Date

Please complete your personal information below.

First Name *

First

Last Name *

Last

Email

Phone *

Date of birth *

Gender *

M

F

Weight (kg) *

Are you an existing patient? *

Yes

No

For each question below, please select the option that best describes you.

Do you snore? *

a) Yes

b) No

c) Don't know

Your snoring is: *

a) Slightly louder than breathing

b) As loud as talking

c) Louder than talking

How often to you snore? *

Has your snoring ever bothered other people? *

a) Yes

b) No

c) Don't know

Has anyone noticed that you stop breathing during your sleep? *

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

During your waking time, do you feel tired, fatigued or not up to par? *

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

a) Yes

b) No

How often does this occur? *

Do you have high blood pressure? *

a) Yes

b) No

c) Don't know