Berlin Questionnaire
First Name
*
Last Name
*
Email
*
Phone
*
1.- Complete the following:
Height
*
Weight
*
Your Age (Years)
Your Sex
*
Your Sex
Male
Female
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2 .- Do you snore?
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Yes
No
Don't know
3.- Your snoring is...
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Slightly louder than breathing
As loud as talking
Louder than talking
Very Loud, can be heard in adjacent rooms
4.- How often do you snore?
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Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
5.- Has your snoring ever bothered other people?
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Yes
No
6.- Has anyone noticed that you quit breathing during your sleep?
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Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
7.- How ofen do you feel tired or fatigued after your sleep?
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Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
Never or nearly never
8.- During your wake time, do you feel tired, fatigued or not up to par?
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Nearly every day
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never
9.- Have you ever nodded off or fallen asleep while driving a vehicle?
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Yes
No
10.- Do you have high blood pressure?
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Yes
No
Don't know
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