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Berlin Questionnaire

This brief screening test utilizes the Berlin Questionnaire and Epworth Sleepiness Scale, as well as a general Patient History Section which combine to provide doctors an accurate tool for identifying people at risk. The test takes between 3 - 5 minutes to complete.

Please remember, this screening test is not meant to diagnose a condition rather offer insight as to the likelihood of someone suffering from Sleep Apnea.

General Information

Male   Female
Date of Birth: (MM/DD/YYYY)
Height: Feet Inches
Weight: Lbs
Age:

Snoring

Do you snore? Sleep Apnea Test
Yes
No
Don't Know
How often have you or your spouse noticed pauses in your breathing? Sleep Apnea Test
Almost everyday
3-4 times per week
1-2 times per week
1-2 times per month
Never or almost never
Are you tired after sleeping? Sleep Apnea Test
Almost everyday
3-4 times per week
1-2 times per week
1-2 times per month
Never or almost never
Are you tired during wake time? Sleep Apnea Test
Almost everyday
3-4 times per week
1-2 times per week
1-2 times per month
Never or almost never
Have you ever fallen asleep while driving? Sleep Apnea Test
Yes
No
Do you have high blood pressure? Sleep Apnea Test
Yes
No
 


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