Berlin Questionnaire

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Two or more positive categories are indicative of a high likelihood of sleep disordered breathing

1. a) What is your age?

1. b) What is your gender?

Male

Female

Clear selection

1. c) What is your weight?

1. d) What is your height?

Category 1

Category 1 is Positive with 2 or more positive responses to questions 2-6

2. Do you snore?

1 point

Yes

Unsure

Clear selection

3. How loud is your snoring?

1 point

Slightly louder than breathing

As loud as talking

Louder than talking

Very loud. Can be heard in adjacent rooms.

I do not snore

Clear selection

4. How often do you snore?

1 point

Nearly every day / Every day

3-4 Times a week

1-2 Times a week

1-2 Times a month

Never or nearly never

Clear selection

5. Has your snoring ever bothered other people?

1 point

Yes

I don't snore

Clear selection

6. Has anyone noticed that you quit breathing during your sleep?

1 point

Yes, nearly daily / daily

Yes, 3-4 Times a week

Yes, 1-2 Times a week

Yes, 1-2 Times a month

No, never or nearly never

Clear selection

Category 2

Category 2 is positive with 2 or more positive responses to questions 7-9

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

1 point

Nearly every day

3-4 times a week

1-2 times a week

1-2 times a month

Never or nearly never

Clear selection

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

1 point

Nearly every day

3-4 times a week

1-2 times a week

1-2 times a month

Never or nearly never

Clear selection

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

Yes

Clear selection

If your answer to the previous question was "Yes", how often does it occur?

1 point

Nearly every day

3-4 times a week

1-2 times a week

1-2 times a month

Nearly never or never

Clear selection

Category 3

Category 3 is positive with 1 positive response and/or a BMI of >30

10. Do you have high blood pressure?

1 point

Yes

Unsure

Clear selection

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