Berlin Sleep Questionnaire

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
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