Please fill in ALL the information needed
When referring to a clinic, please attach the BERLIN SLEEP EVALUATION and EPWORTH
SLEEPINESS SCALE (ESS) questionnaires to the CHOOSE & BOOK referral request together with
the referral letter electronically
BERLIN QUESTIONNAIRE
SLEEP EVALUATION
Name:
D.O.B.
Height (m):
Age:
weight (kg):
Neck (cm):
►IMPORTANT: Please give only one answer per question by typing Yes in the relevant boxes
1
Has your weight changed?
7
Increased
Decreased
No change
Category 1
Do you snore?
Yes
No
Don't know
3
Snoring loudness
Loud as breathing
Loud as talking
Louder than talking
Very loud
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 you snoring ever bother other
people?
Yes
No
Don't know
Nearly every day
3 - 4 times a week
1 - 2 times a week
1 - 2 times a month
Never or nearly never
Category 2
2
8
During your awaking 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
9
Have you ever nodded off or
fallen asleep while driving a
vehicle?
Yes
No
Category3
10
6
How often are you tired or
fatigued after sleeping?
Do you have high blood
pressure?
Yes
No
BMI (= Weight/(Height x Height)
(Please calculate and type in)
How often have your breathing pauses
been noticed?
Nearly every day
3 - 4 times a week
1 - 2 times a week
1 - 2 times a month
Never or nearly never
Scoring Questions: Any answer on blue bold is a positive response.
BERLIN QUESTIONNAIRE RESULTS
Scoring Categories (please type the results in the grey boxes:
▪
Category 1 is positive with 2 or more positive responses to questions 1-6
▪
Category 2 is positive with 2 or more positive responses to questions 7-9
▪
Category 3 is positive with 1 or more positive responses and/or a BMI>30
BMI =
Final Results:
2 or more positive categories indicates a High Risk of OSAH & ESS ≥11 (see next page); please book patients
for Sleep Limited Study (SLS).
Low Risk of OSAH and Epworth Sleepiness Scale (ESS) ≥11; please refer patient to Sleep clinic
Low Risk of OSAH and Epworth Sleepiness Scale (ESS) <11; please refer patient to ENT clinic
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EPWORTH SLEEPINESS SCALE (ESS)
Patient self assessment questionnaire
Please fill in the following questionnaire by filling in a number in the box by each situation
In each situation, please try and estimate the chance of you dozing
Would NEVER doze
0
SLIGHT chance of dozing
MODERATE chance of dozing
1
2
HIGH chance of dozing
3
Sitting reading a book
Watching television
Sitting inactive in a public place e.g. in a meeting
Lying down to rest in the afternoon
Sitting talking to someone
Sitting quietly after a lunch without alcohol
In a car, stopped in traffic or at lights
In a car, as a passenger for an hour
Epworth Sleepiness Scale (ESS) TOTAL
(Please add up results typed above and
type result in the grey box)
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