Berlin Questionaire

1. Demographics:

Sex:

First Name:

Last Name:

Height:

Weight:

Age:

2. Do You Snore?

7. How often do you feel tired or
fatigued after your sleep?

If You Snore:
3. Your snoring is?

8. During your wake time, do you
feel tired, fatigued or not up to par?

4. How often do you snore?

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

5. Has your snoring ever bothered
people?

If yes, how often does it occur?

6. Has any one noted that you quit
breathing during your sleep?

10. Do You have high blood pressure?

Northwind Lung Specialists & Sleep Center
3758 Coon Rapids Boulevard
Coon Rapids, MN 55433
Phone:763-746-9463 Fax:763-746-9473