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Complete the following survey (a combination of the Berlin Questionnaire and Epworth Sleepiness Scale) to assess for your risk level for having Obstructive Sleep Apnea. Your answers will be scored automatically and results will be given after you submit.

Epworth Sleepiness Scale

Age:

Sex: Male Female

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired?

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g. a theatre or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in the traffic

Berlin Questionnaire

Height (in) Weight (lb)

Please choose the correct response to each question.

Category 1 1. Do you snore? Yes No Don't Know	Category 2 6. How often do you feel tired or fatigued after your sleep? Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
If you snore: 2. Your snoring is: Slightly louder than breathing As loud as talking Louder than talking Very loud - can be heard in adjacent rooms	7. During your waking time, 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
3. How often do you snore: Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never	8. Have you ever nodded off or fallen asleep while driving a vehicle? Yes No
4. Has your snoring ever bothered other people? Yes No Don't know	9. How often does this occur? Nearly every day 3-4 times a week 1-2 times a week 1-2 times a month Never or nearly never
5. 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	Category 3 10. Do you have high blood pressure? Yes No Don't know

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