ResMed 

Berlin Questionnaire                                                            Sleep Evaluation

1. Please Complete the Following:

Height:  
          

ft.
in.		 Age:

Weight:

lbs.
Male:        Female:
Name:       
Address:  
City:       State: Zip:
2. Do You Snore?
Yes
No
Don't Know.

If You Snore:
3. Your Snoring is:
Slightly louder than breathing
As loud as talking 
Louder than talking
Very loud
4. How often do you Snore?
Almost every day
3-4 times a week 
1-2 times a week   
Never or almost never 
5. Does your Snoring bother other people?
Yes
No
6. Has anyone noticed that you quit breathing during your sleep?
Almost every day
3-4 times a week
1-2 times a week
Never or almost never
7. Are you tired after sleeping?
Almost every day
3-4 times a week
1-2 times a month
Never or almost never
8. Are you tired during wake time?
Almost every day
3-4 times a week
1 time a month
Never or almost never
9. Have you ever nodded off or fallen asleep while driving?
Yes
No
9b. If yes, how often does it occur?
Almost every day
3-4 times a week
1-2 times a week
Never or almost never
10. Do you have high blood pressure?
Yes
No
Don't Know

©   Copyright Annals of Internal Medicine 1999. The Berlin Questionnaire is reproduced with the permission of the American College of Physicians.