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I am ready to screen admin 2017-06-30T13:20:32+00:00

BERLIN QUESTIONNAIRE

1 Start

2 Patient Information

3 Height

4 Category 1: Snoring

5 Category 2: Sleepiness

6 Category 3: History

7 Choose the right solution for your needs

8

9

Do You Have Sleep Apnea?

Prefix*
First Name*
Last Name*
Sex*
Email*
Phone
Date Of Birth*

Feet*
Inches*
Weight*
In Pounds

Do you snore?*
- Yes
- No
- Don't Know
Your snoring is?
- slightly louder than breathing
- as loud as talking
- louder than talking
- very loud
How often do you snore?
- Almost everyday
- 3-4 times per week
- 1-2 times per week
- 1-2 times per month
- Never or almost never
Has your snoring ever bothered other people?
- Yes
- No
How often have you or your spouse noticed pauses in your breathing?
- Almost everyday
- 3-4 times per week
- 1-2 times per week
- 1-2 times per month
- Never or almost never

How often do you feel tired or fatigued after your sleep?
- Almost everyday
- 3-4 times per week
- 1-2 times per week
- 1-2 times per month
- Never or almost never
Are you tired during waketime?
- Almost everyday
- 3-4 times per week
- 1-2 times per week
- 1-2 times per month
- Never or almost never
Have you ever fallen asleep while driving?
- Yes
- No
How often?
- Almost everyday
- 3-4 times a week
- 1-2 times a week
- 1-2 times a month
- Never or almost never

Do you have high blood pressure?
- Yes
- No
- Don't know
Body Mass Index (BMI)*
Calculator

{Prefix:10} {First Name:1} {Last Name:2} Thank you for taking the time to see if you have Sleep Apnea by filling out the Berlin Sleep Apnea Assessment. Based upon your answers you are Negative for Sleep Apnea.
{Prefix:10} {First Name:1} {Last Name:2} Thank you for taking the time to see if you have Sleep Apnea by filling out the Berlin Sleep Apnea Assessment. Based upon your answers you are Positive for Sleep Apnea.

Do you have a physician that you see regularly?*
- Yes
- No
Home Sleep Test With Your Physcian Persciption

Our Price: $299.99

Convenient - Utilizes your personal physician prescription
Fast - As little as 1 week with expedited shipping
Accurate - High accuracy level - equivalent in effectiveness to facility-based testing
Affordable - Only $299 vs. thousands of dollars for a facility-based sleep test
Home Sleep Test With Telemedicine Prescription

Our Price: $399.99

Convenient - Utilizes Our Telemedician physician prescription
Fast - As little as 1 week with expedited shipping
Accurate - High accuracy level - equivalent in effectiveness to facility-based testing
Affordable - Only $399 vs. thousands of dollars for a facility-based sleep test
Price*
Price: $299.99

Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Note: Your credit card statement will reflect two charges one from VirtuOx, Inc. for the Sleep Apnea Home Test and the other from Care Centered, LLC for the physician consultation.

BERLIN QUESTIONNAIRE

1 Start

2 Patient Information

3 Height

4 Category 1: Snoring

5 Category 2: Sleepiness

6 Category 3: History

7 Choose the right solution for your needs

8

9

Do You Have Sleep Apnea?

Prefix*
First Name*
Last Name*
Sex*
Email*
Phone
Date Of Birth*

Feet*
Inches*
Weight*
In Pounds

Do you snore?*
- Yes
- No
- Don't Know
Your snoring is?
- slightly louder than breathing
- as loud as talking
- louder than talking
- very loud
How often do you snore?
- Almost everyday
- 3-4 times per week
- 1-2 times per week
- 1-2 times per month
- Never or almost never
Has your snoring ever bothered other people?
- Yes
- No
How often have you or your spouse noticed pauses in your breathing?
- Almost everyday
- 3-4 times per week
- 1-2 times per week
- 1-2 times per month
- Never or almost never

How often do you feel tired or fatigued after your sleep?
- Almost everyday
- 3-4 times per week
- 1-2 times per week
- 1-2 times per month
- Never or almost never
Are you tired during waketime?
- Almost everyday
- 3-4 times per week
- 1-2 times per week
- 1-2 times per month
- Never or almost never
Have you ever fallen asleep while driving?
- Yes
- No
How often?
- Almost everyday
- 3-4 times a week
- 1-2 times a week
- 1-2 times a month
- Never or almost never

Do you have high blood pressure?
- Yes
- No
- Don't know
Body Mass Index (BMI)*
Calculator

{Prefix:10} {First Name:1} {Last Name:2} Thank you for taking the time to see if you have Sleep Apnea by filling out the Berlin Sleep Apnea Assessment. Based upon your answers you are Negative for Sleep Apnea.
{Prefix:10} {First Name:1} {Last Name:2} Thank you for taking the time to see if you have Sleep Apnea by filling out the Berlin Sleep Apnea Assessment. Based upon your answers you are Positive for Sleep Apnea.

Do you have a physician that you see regularly?*
- Yes
- No
Home Sleep Test With Your Physcian Persciption

Our Price: $299.99

Convenient - Utilizes your personal physician prescription
Fast - As little as 1 week with expedited shipping
Accurate - High accuracy level - equivalent in effectiveness to facility-based testing
Affordable - Only $299 vs. thousands of dollars for a facility-based sleep test
Home Sleep Test With Telemedicine Prescription

Our Price: $399.99

Convenient - Utilizes Our Telemedician physician prescription
Fast - As little as 1 week with expedited shipping
Accurate - High accuracy level - equivalent in effectiveness to facility-based testing
Affordable - Only $399 vs. thousands of dollars for a facility-based sleep test
Price*
Price: $299.99

Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Note: Your credit card statement will reflect two charges one from VirtuOx, Inc. for the Sleep Apnea Home Test and the other from Care Centered, LLC for the physician consultation.

VirtuOx Inc. has received full accreditation by The Joint Commission as an Ambulatory Care Sleep Diagnostic Center

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