Berlin test – VitalAire Schweiz AG

Berliner test*

Please answer these questions:

SNORING

Do you snore? *

Yes

I don't know

None

You snoring is: *

Slightly louder than breathing

As loud as talking

Louder than talking

Very loudly

None

How often do you snore? *

Almost every day

3-4 times per week

1-2 times per week

Rarely or never

None

Has your snoring ever bothered other people? *

Yes

None

Has anyone noticed that you stop breathing during your sleep? *

Almost every day

3-4 times per week

1-2 times per week

1-2 times per month

Rarely or never

None

FATIGUE

During your waking time, do you feel tired, fatigued or not up to par? *

Almost every day

3-4 times per week

1-2 times per week

1-2 times per month

Rarely or never

None

How often does this occur? *

Almost every day

3-4 times per week

1-2 times per week

1-2 times per month

Rarely or never

None

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

Yes

I don't know

None

How often does this occur? *

Almost every day

3-4 times per week

1-2 times per week

1-2 times per month

Rarely or never

None

RISK FACTORS

Do you have high blood pressure? *

Yes

I don't know

None

Time's up

Sleep apnea can be treated, talk to your loved ones and contact us!

*Those results are not a diagnostic and do not replace a medical exam.

Name *
First name *
Adresse *
ZIP *
City *
Phone
Mobile
E-mail *

Message
I explicitly accept the use of my data in the context of a single contact with the selected address.
I can request the deletion of my personal data by sending a letter to :

VitalAire Schweiz AG
Waldeggstrasse 38
3097 Liebefeld

Tel. 031 978 78 82

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Integrated Respiratory Care

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