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Berlin Questionnaire
Step
1
of
2
- Personal Information
50%
Personal Information
Name
(Required)
First
Last
Gender
(Required)
Male
Female
Other
Height
(Required)
In meters
Age
(Required)
Weight
(Required)
In kilograms
Category 1
Do you snore?
(Required)
Yes
No
Don't know
If you snore, is your snoring:
(Required)
Slightly louder than breathing
As loud as talking
Louder than talking
How often do you snore?
(Required)
Almost every day
3-4 times a week
1-2 times per week
1-2 times per month
Rarely or never
Has your snoring ever bothered other people?
(Required)
Yes
No
Don't know
How often do you snore?
(Required)
Almost every day
3-4 times a week
1-2 times per week
1-2 times per month
Rarely or never
Category 2
How often do you feel tired or fatigued after your sleep?
(Required)
Almost every day
3-4 times a week
1-2 times per week
1-2 times per month
Rarely or never
During your waking time, do you feel tired, fatigued, or not up to par?
(Required)
Almost every day
3-4 times a week
1-2 times per week
1-2 times per month
Rarely or never
Have you ever nodded off or fallen asleep while driving a vehicle?
(Required)
Yes
No
If you snore: How often does this occur?
(Required)
Almost every day
3-4 times a week
1-2 times per week
1-2 times per month
Rarely or never
Category 3
Do you have high blood pressure?
(Required)
Yes
No
Don't know
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Treatment Options
Oral Appliance Therapy
Snoring and Sleep Apnea
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Snoring
Sleep Apnea
Sleep Assessment​
Forms & Resources
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Expand
Patient Care
Pre-Treatment Sleep Questionnaire
New Patient Form
Insurance Package
