BERLIN QUESTIONNAIRE

1. Complete the following: Height Inches Age Weight lbs Gender Male Female

2. Do you snore? yes no don't know

If you snore: 3. Your snoring is? I do not snore 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? Never or nearly never 1-2 times a month 1-2 times a week 3-4 times a week Nearly every day

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 you sleep? Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month 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

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

10. Do you have high blood pressure? Yes No don't know

Contact information: Name Email