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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?
Yes
No
I dont know
If you snore:
3. Your snoring is:
Slightly louder than breathing
As loud as talking
Louder than talking
Very loud can be heard in adjacent
4. How often do you snore?
Nearly every day
3-4 times/week
1-2 times/week
1-2 times/month
Never or nearly never
5. Has your snoring bothered other people?
Yes
No
6. Has anyone ever noticed that you quit breathing during your sleep?
Nearly every day
3-4 times/week
1-2 times/week
1-2 times/month
Never
7. How often do you feel tired or fatigued after your sleep?
Nearly every day
3-4 times/week
1-2 times/week
1-2 times/month
Never
8. During your awake time, do you feel tired, fatigued or not up to par?
Nearly every day
3-4 times/week
1-2 times/week
1-2 times/month
Never or nearly never
9. Have you ever nodded off or fallen asleep when driving a vehicle?
Yes
No
If yes, how often does it occur?
Nearly every day
3-4 times/week
1-2 times/week
1-2 times/month
Never or nearly never
10. Do you have high blood pressure?
Yes
No
