Epworth Sleepiness Scale

Date

Personal Information

Please complete your personal information below.

First Name *

First

Last Name *

Last

Email

Phone *

Date of birth *

Gender *

M

F

Are you an existing patient? *

Yes

No

How likely are you to doze or feel sleepy in the following situations, in contrast to feeling just tired?

This refers to your usual way of life in recent times.

Even if you haven't done some of these things recently try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation.

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

It is important that you answer each questions as best you can.

Sitting and reading *

0

1

2

3

Watching TV *

0

1

2

3

Sitting, inactive in a public place (e.g. a theatre or a meeting) *

0

1

2

3

As a passenger in a car for an hour without a break *

0

1

2

3

Lying down to rest in the afternoon when circumstances permit *

0

1

2

3

Sitting and talking to someone *

0

1

2

3

Sitting quietly after a lunch without alcohol *

0

1

2

3

In a car, while stopped for a few minutes in the traffic *

0

1

2

3