Berlin Questionnaire
Sleep Evaluation in Primary Care
1. Complete the following:
Height: Weight:
Age: Gender: M F


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. Can be heard in adjacent rooms

4. How often do you snore?:
Nearly every day.
3-4 times a week
1-2 times a week
never or nearly never


5. Has your snoring ever bothered other people?:
Yes
No


6. Has anyone noticed that you quit breathing during your sleep?:
Nearly every day.
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never
7. How often do you feel tired or fatigued after your sleep?:
Nearly every day.
3-4 times a week
1-2 times a week
never or nearly never

8. During your waketime, do you feel tired, fatigued, or not up to par ?:
Nearly every day.
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never

9. Have you ever nodded off or fallen asleep while driving a vehicle?:
Yes
No


10. If yes, how often does it occur?:
Nearly every day.
3-4 times a week
1-2 times a week
1-2 times a month
never or nearly never


11. Do you have high blood pressure?:
Yes
No
Don't know

BMI =
 
Name:
Address:
Phone:

Scoring Questions: Any answer within a box outline is a positive response

Scoring Categories:
Category 1 is positive with 2 or more positive responses to questions 2-6
Category 2 is positive with 2 more positive responses to questions 7-9
Category 3 is positive with 1 positive response &/or a BMI > 30

4319 Medical Drive. Suite 211
San Antonio, Texas 78229
Phone (210) 614-9775 Fax (210) 614-2891

Final Result : 2 or more positive categories indicate a high likelihood of sleep disordered breathing