Berlin Sleep Questionnaire - Dental Sleep Medicine of Greenville

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» Obstructive Sleep Apnea
» Central Sleep Apnea
» Snoring
» TMJ Treatment
» Treatment Options
» FAQ
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Berlin Sleep Questionnaire

Based on your response you are at Risk for Sleep Apnea. Schedule a FREE Consultation with Dental Sleep Medicine of Greenville by filling out the form below.

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NAME * EMAIL ADDRESS * PHONE * MESSAGE *
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Berlin Sleep Questionnaire
(Ask Your bed partner questions 2-6)

Dental Sleep Medicine of Greenville
Leor Lindner, D.M.D.
40 Pointe Circle
Greenville, SC 29615
864.909.2672

Date

1. Please complete the following:

First Name

Last Name

Email

Phone

Height FT/IN

Weight LB

Age

M/F

2. Do you snore?
YesNoI dont know

If you snore:
3. Your snoring is:
Slightly louder than breathingAs loud as talkingLouder than talkingVery loud can be heard in adjacent

4. How often do you snore?
Nearly every day3-4 times/week1-2 times/week1-2 times/monthNever or nearly never

5. Has your snoring bothered other people?
YesNo

6. Has anyone ever noticed that you quit breathing during your sleep?
Nearly every day3-4 times/week1-2 times/week1-2 times/monthNever

7. How often do you feel tired or fatigued after your sleep?
Nearly every day3-4 times/week1-2 times/week1-2 times/monthNever

8. During your awake time, do you feel tired, fatigued or not up to par?
Nearly every day3-4 times/week1-2 times/week1-2 times/monthNever or nearly never

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

If yes, how often does it occur?
Nearly every day3-4 times/week1-2 times/week1-2 times/monthNever or nearly never

10. Do you have high blood pressure?
YesNo

Doctor Referral
Doctor Name: * Practice Name: Best Email Address: * Name of the Patient You are Referring: * Patient's Phone Number: * Patient's Email Address: * Comments:
Submit Referral

NEW PATIENT ONLINE REGISTRATION

Obstructive Sleep Apnea

Snoring

Central Sleep Apnea

TMJ Treatment

Treatment Options

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LOCATION-40 POINTE CIR GREENVILLE,SC 29615 864-485-6655
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Dental Sleep Medicine of Greenville
40 Pointe Cir Greenville SC 29615 (864) 485-6655
DIRECTIONS

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Take The Sleep Apnea Risk Quiz

At Night Do You do 1 or more of...Snore? Stop breathing while sleeping? Wake up gasping or choking? Awaken frequently? Grind your teeth? Wake up frequently to urinate?*

During the Day, Do You... Feel sleepy or unintentionally doze? Have headaches in the morning? Have difficulty with memory or concentration? Awake tired even after a full night’s sleep? Breathe through your mouth? *

Do you have any of these symptoms... Overweight or obese ,Coronary artery disease, High blood pressure, Congestive heart failure, Neck size > 17 (men) Neck size > 15 (women), Acid reflux or heartburn, Stroke, Type II Diabetes, Insomnia, Depression or Erectile Dysfunction*

Send
NEW PATIENT ONLINE REGISTRATION